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1. SRWAGE <br /> ,J <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: /3-4 <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 /> Licensed scavenger pick-up: Yes.,,./— No_ Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY, MOSQUITO OR VRCTOR PO'f :.NT' TTAL <br /> State possible vector potential & necessary control: <br /> 5 . TO . .T/BATH FACTLTTES <br /> No. & location existing: �\ Additional <br /> facilities needed <br /> 6. PREVIOUS CPRRATTON HISTORY /^ <br /> =r <br /> 7 . GENERAL SANTTATTON <br /> State any problems not previously noted: <br /> 8 . POPTILATTON nENSTTY <br /> Appx. No. People per eq. mi. <br />