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1 . 2EWAGE <br /> Distance to Public Sewers Connection Connection necessary : Yes No.,- <br /> Does existing septic system comply with Ord . 0549 : Yes No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well: Yes .� No Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public water: Yes <br /> No Sample of well water taken: Yes Nom. Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSF <br /> Licensed scavenger pick-up: Yes _k' No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem <br /> 4 . Fes, MOSQUITQ OB VECTOR CT EC)r2NjALL <br /> State possible vector potentiftl & necessary control : <br /> 5 . TOILET/BATH FACTT,TI'FS <br /> No . & location existing: , Additional <br /> facilities needed <br /> 6 . PREVIOUS OP .RATION HIST_ RY <br /> 7 . GENERAL SANITATION <br /> State any problem not Previously noted: <br /> 9 . T-10PULATTQ14 Dr LI-)TI:v <br /> ApPx . No . People per r3q. mi .��•�icr%��v. —�F��� ��-� <br />