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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_ <br /> Does existing septic system comply with Ord . #549 : Yeses 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 /> Yees No State deficiency : <br /> I a <br /> Does existing or purposed 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 /> L ensed scavenger pick-up: Yes No Service Area No. -"' <br /> Oth r proposed disposal method: <br /> Pote ial problem: <br /> 4 . FLY,- MOS UTTQ _YiT� NTIAL <br /> State pons ' e vector potential & necessary control : <br /> f <br /> 5 . TQILET/BATH FAC I TTS <br /> No . & location existing:' Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATIO HT Tf2BY <br /> 7 . GENERATE SANTTA`-0 <br /> State any prof)11Ems nt�t previously noted ., - <br /> 8 . <br /> oted : _8 . It N DENSITY <br /> pk: No . People per sq. mi .- <br />