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1. SEWAal <br /> Distance to Public Sewers Connection necessary: Yes ti No— <br /> Does existing septic system comply with Ord. #549 : Yes No— <br /> Unknown If no, explain: <br /> Describe septic installation to 'be installed: <br /> 2. WATER SUEPLY <br /> Is water supplied. by private well : Yes Flo Is well proper: <br /> Yes No State deficiency: <br /> Does existing or porposed use make this well public crater: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licenned scavenger pick--up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. ELY, MQSdUITO 0A VE TO POTENTIAL <br /> State possible vector potential & necessary control: <br /> 5. T.91LET/BATH FACILITEa <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PRE11QUE CEERAITQH _IH STnRX <br /> 7. GENERAL SANITATION <br /> State any problems not previously noted: <br /> a . pC1j2iLATION DEHLTy <br /> Appx. No. People per .ocl. Mi. <br />