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1 . AGE. <br /> Distance to Public Sewers Connection necessary: Yes No..,�.. <br /> Does existing septic system comply with Ord. #549 : Yes No ' r <br /> Unknown If no, explain: Geac-t„ 4,,e)J G,; r� rJ4w lx'.�J ori Par e l OZ <br /> 15 v K d aro i- ��c C ' 5 r e, <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 /> W.q d O f b <br /> Does exj-s 4Tg-Gr— pose.d-u.Qe make this well public water: Yes <br /> No==-- S-amp-1­e-of well water taken: 'des No Date taken <br /> R•eau1ts7Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes Y""' <br /> No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . F1,X I OSOUI' o— Q13_YECTOR PC}' RziI L <br /> Stat possible vector potential & necessary control : <br /> 5 . IDTLETZEaTLEACILIMa <br /> No. & locatio existing : _ Additional <br /> facilities need d <br /> 6 . FREVTQua OPE N TSTORY <br /> 7 . GENERAL SANI'TAL'IM <br /> State any problems not prev Iau ly rioted:_ <br /> 3 . Y <br /> Appx. No . People per sq. mi . <br />