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No v s r. <br /> N,( <br /> 1 . SEWAGE <br /> Distance to Public Sewers Connection necessary : Yes_ No_ <br /> Does existing septic system comply with Ord . 0549 : Yes_ No_ <br /> Unknown If no, explain: //c� <br /> k1lr Ae� SN�kti�- tov , <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 /> �al- �� t-- <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 & R .F USE <br /> Licensed scavenger pick-up: Yes— No_ Service Area No. <br /> Other proposed disposal me hod: <br /> Potential problem: <br /> 4 . FiLY-� MOSQUITO OR VECTOR ZC)M IAu <br /> State possible vector potentir,l & necessary control : <br /> /,7 <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed —_ <br /> 6 . PREVIOUS OPLRATIDA HISTOL <br /> 7 . GENERAL SAtiI'PAT ON <br /> State any problems not previously noted: <br /> 3 . PO P i[,ATION DEL�J,-TJY <br /> Appx . No . People per sq. mi . <br />