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1. S SWAG <br /> Distance to Public Sewers Connection necessary: Yes No— <br /> Does existing ' septic system comply with Ord. #549 : Yes No_._, <br /> Unknown If no, explain: i <br /> Describe septic installation to 'be installed: <br /> 2. WATER SUPELY <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: 'les <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licenced scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FL,. MnS47UtTQ QRVr,Q TQBpSt'�+N, TIAL <br /> State possible vector potenti{tl & necessary control: <br /> 5 . TOILETZBATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> B . PREVTORS OPERATION HISTORY <br /> 7. GENERAL SANITATION_ <br /> State any problems not previously noted: <br /> 8 . POPULAITQN DENST_TY <br /> Apex. No. People per aq. mi. <br /> r. <br />