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1 . 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 porpoeed use make this well public water: Yes- <br /> No­ <br /> esNo _. Sample of well water taken: Yes No Date taken <br /> - <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licenaed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem:_ <br /> 4. FLY. M0SOUTTQ OR Vra T0QR PUMU TA . <br /> State possible vector potentiftl F.c necessary control: <br /> 5. TQTLET/BATH FA(_.IL ITF.3 <br /> No. & location existing: Additional <br /> facilities needed- <br /> 6. PREVIOUS QBT0,AMLQ-Jt-Ji151QRX <br /> 7 . GENERAL SAIIIIA' TQIJ <br /> State any problems not previouvly noted: <br /> 3 . POPU .AT <br /> Appx . No . People per aq. mi. <br />