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s <br /> ll 1 <br /> 1 'SEWAGE <br /> Distance to Public Sewers - — Connection necessary: Yes No,4l_ <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 wa er supplied by private well : Yes -,A-' No Is well proper: <br /> Yes-4- No State deficiency : <br /> Doe 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 corrmen"ts <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No.� Service Area No. <br /> Other proposed disposal method : <br /> Potential problem! <br /> 4 . FLYL MOSQUITO OR_y F11 QT Q R __.�)T=AL <br /> State possible vector poteiitiFtl & necessary control : <br /> 5 . TOILET/BATH F-ball—UM <br /> No. & location existing : Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTCa <br /> 7 . GENERAL SANT IA`s 0B. <br /> State any problems not previously noted: r'y4�c"- <br /> 8 . <br /> Appx. No . People per sq . m:i_ . <br />