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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes Nd,,, <br /> Does existing septic system comply with Ord. #549 : Yes No_' <br /> Unknown If no, explain: <br /> Describe septic installationtobe installed: <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes Nom Is well proper: <br /> Yes No State deficiency: <br /> Doe"xisting or porposed use make this well public water: Yes <br /> No Sample of well water -taken: Yes NoDate taken <br /> Results \\ Additional information or comments <br /> 1 <br /> \ ^L J C✓c..� C.. o r i-�?rc_ p LJ (.1� Lz-2. f� ✓t r E-�t <br /> k ^U�r /�E � O � �Q C I �'(l hT7hr-i,'�,�Uv" �--�C.� r �!J✓'� (N(/ <br /> 3 . GARBAGE & REFUSE J <br /> . Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FLI, MOSQUITO OR ECTOR POTENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TQILETIBATH FACILITES <br /> No. & location existing :_ Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SAP ITATI- . <br /> State any problems not previously noted : _ _ <br /> S . P'OPULATIQN DENSITY <br /> Appx. No. People per sq. mi . <br />