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A r <br /> 1 . UWAGE <br /> Distance to Public Sewers Connection necessary: Yes Nom <br /> Does existing septic system comply with Ord . 31549 : Yes No„ <br /> Unknown If no, explain: <br /> Describe septic inetal.lat on to be install,ed: fi.�f�.�l�,�� <br /> �yy �- <br /> 2 . WATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes NO State def iciency <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 . GARBAGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No . <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . =.,,_ M O sQ U I T Q 0E VZ^T O PL'I'.�NTIA"1 <br /> State possible vector potentiftl & necessary control : 50�w� <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PRFVIOfT5 OPERATION HISTORY <br /> 7 . 0 E N 1BAL SA I'r TJ�?r_1 <br /> State any problems not previously noted: �� <br /> 8 . EOPULATION Dr i r�i <br /> Appx. No . People per 6q . mi . /��i�d����E — ��✓i������ <br />