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I <br /> 1 . SEWAGE <br /> Distance to Public Sewers�l. Connection necessary : Yes_ No-=— <br /> Does <br /> o_Does existing septic system comply with Ord . 11549 : Yes_ No_ <br /> Unknown If no, explain: <br /> Des-a is installation to be installed: <br /> 2 . WATER SUPPLY <br /> Is wat supplied by private well : Yes No_ Is well proper: <br /> Yee No_ State deficiency :_ <br /> Does existing or porposed use make this well public water : Yes <br /> No Sample of well water taken: Yes_ No_ Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE. & RFFUSF <br /> Licensed scavenger pick-up: Yes_ No_ Service Area No . <br /> Other proposed disposal method: <br /> Potential problem : <br /> 4 . Eiji NnSoUITQ Rv 2.TO pSrX <br /> State possible vector potentir,l & necessary control : <br /> 5 . TOILET/BATH FACUTTES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PRFVIOOS OPERATION HISTORY <br /> ��� -ls� .�/�: -, a/ �' Yom'-Q�_��.Gir_i �� ✓Z fry <br /> 7 . GENE,RAL LJjjATION <br /> State any problems not previously �otfi eci : _� ` <br /> 8 . POPULATTON DENSTIv. <br /> Appx . No . People <br /> per sc1 , mi . <br />