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1 . SEWAGR <br /> Distance to Public Sewers Connection necessary: Yes_ No--:s-- <br /> Does existing septic system comply with Ord . #549 : Yes, No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: �F <br /> 2 . MATER S[IPPL'I <br /> Is wa er supplied by private well : Yes X- No— Is well proper: <br /> Yes No_ State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> NoSample of well water taken: Yes_ No� Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & R .F TS . <br /> Licensed scavenger pick-up: Yesz, No_ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY. MOSQUITO OR VECTOR Ri, ENTIAL <br /> State possible vector potential & necessary control :—,:� <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: Additional <br /> facilities needed _ <br /> 6. PREVIOf7S OPERATION HISTORY <br /> 7 . GENERAL SAPS '1T TION <br /> State any problems not previously noted: <br /> 3 . POPULATION DENSITY <br /> APpx. No . People Per sq. mi . /I�� �'✓��.�f ��Ff�Gfi� 7/'l <br />