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SEWAGE <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 : <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 /> 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 & REFUSE <br /> Licenced scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . F.L`L- MOSQUITO ORVZQ-T-QJ1–gsi""r.EN 1AL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed <br /> 6 . PREVIOr_i2 nPERATION HISTP`U <br /> 7 . GENERAL SAIJIT '1A 'ION <br /> State any problems not previously noted : - <br /> 8 . <br /> oted : _8 . POPULATIQ14 Dr N STTY <br /> Appx . No . People per t3q . mi . <br /> - - P�C- ? � <br />