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r i <br /> 1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yee N4-)— <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 X No Is well proper: <br /> Yes 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 . <br /> Lice sed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potent al problem: <br /> 4 . ELY ECTOR PO'T'ENTIAL <br /> State pos ible vector potential & necessary c:or�trol : <br /> t6 <br /> T <br /> 5 . TOILET/BATH FA <br /> CI ' <br /> No . & location exi ting: Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HI�S& <br /> 7 . GENERAL SANITATION <br /> State any problems" riot previously r� ted: _—_ <br /> r <br /> 3 POPULATION L NSITY <br /> Appx. No . ,People per sq. mi . <br />