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1 . SEWAGF� <br /> Distance to Public Sewers _ Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . 3x549 : Yes No_ <br /> Unknown If no, explain : <br /> Describe septic installation to be installed: <br /> 2. WATER SUPPLY <br /> Is dater supplied by private well : Yes iIo 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 & REFUSE <br /> Licenced scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLY . MOSQUTTO OR VZ,.TnR ZC)[ENTIAL, <br /> State possible vector potential ex necessary control: <br /> 5 . TOILETfBATH FACILITES <br /> No. ec location existing: Additional <br /> facilities needed <br /> 6 . PRFVIOnS nPERATION HISTORY <br /> 7 . GENERAL SANITa:'TON <br /> State any problems not previously noted: <br /> 3 . P. JLATIOta 172EH,-3ITY <br /> Appx. No . People per aq . mi . <br />