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l <br /> 1 . SWAGE <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . #5.49 : Yes No_ <br /> Unknown If nd, explain : <br /> Describe septic installation to be installed: <br /> <� 0- s z �.x�a t e� G i rr Tl� <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No -s 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: Fs No Date taken <br /> Results ,_tt____ Additional in,formatin-i /or comments <br /> 2_LA� C�r.J�1 w(�il� yx"dv <br /> 3 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential' problem: --4 . FLYi (7SOUITta OR_Yrl�T� <br /> State possible. vector potential necessar ontrol - <br /> f,. <br /> 5 . ET/BATH/BATH LACULUi <br /> No . & location existing : ° . Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION H= <br /> 7 . GENERAL SANI'_rAUQU, <br /> State any problems not previousl noted : _ — <br /> S . POP LLATI_(_UL1EAa1T� <br /> Appx. No. People per rr,i . <br />