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. 2rWAGF <br /> Distance to Public Sewers Connection necessary: Yes No_ <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 . MATER SUPPLY <br /> Is water supplied by private well : Yes � No Is dell proper: <br /> Yee . No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No Semple of well water tarsen: 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: f � <br /> 4 . Fill- MOSQUITO OR VZ^.TO �i'j' ,i1TTA <br /> State possible vector potentiFtl necessary control : <br /> 5 . TOILET/BATH FACI ETES <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVTO(_iS OPERATION HISTORY <br /> 7 . GENERAL SAIL11A_Lt—1 <br /> State any problems not previously noted: _ <br /> 8 . 200 LATION DUS?TY <br /> Appx. No . People per rq. mi . <br />