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1. SHWACaR <br /> Distance to Public Sewers Connection necessary: Yes <br /> Does existing septic system comply with Ord. #549 : Yes No_. <br /> Unknown If no, explain: <br /> DescVejepti installation to 'be installed: �� <br /> 2. MATER SUPPLY <br /> Is water supplied by private well: Yes Z— No Is well proper: <br /> Yes � No State deficiency: <br /> Does a isting 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 V, No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY. MOSQUTTO OR YMQTOR PO'[2,NTTAL <br /> State possible vector potential 8.c necessary control: <br /> 5 . TOILET/BATH FACIUTES <br /> No. ec location existing: Additional <br /> facilities needed <br /> 6. PRF�VIOUS OPERATION HISTORY <br /> 7 . UENERAL SANT_IATION <br /> State any problems not previously noted: <br /> / <br /> / 1il" <br /> 8 . POPULATION DENSITY <br /> Appx. No. People per eq. mi. <br />