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1 . S E W A Q2 <br /> Distance to Public Sewers Connection necessary : Yes No_ <br /> Does existing septic system comply with Ord . #549 : Yes No_ <br /> 11 Unknown If no, explain: <br /> �./I�l..� '� 1 J�o-�kQ Ol!• ci� r o►4 �p T, t�Q f rr -� _ � <br /> f�o �, r • A'v -iA= <br /> Describe septic installation to be installed : <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes L!�--No State deficiency : <br /> x3 0?r 7 1 <br /> v-:-:s u y w L1r Gyc. w 2E_� 4 <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 . FLY . MOSQUITO OR VECTOR POTENTIAL <br /> State possible vector potential & necessary control : <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing : Additional <br /> facilities needed <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted : <br /> 8 . POPULATION DENSITY <br /> Appx . No . People per sq . mi . <br />