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1 . SEWAGE <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 L__­1�10 Is well proper: <br /> Yesy o State def4cieney : <br /> Does existing or porposed use make this well public water: Yes <br /> No Semple 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 . <br /> roblem:4 . ElLy_L MOSQUITO QB VEQTOR PQ r=TAlu <br /> State- possible vector potentiitl ry control: <br /> 5 . TOILET/BATH FACILITES <br /> No . & location existing: _ Additional <br /> facilities needed _ <br /> 6 . PREVIOTTS OPERATION r <br /> ------------ <br /> 7 . GENERAL SA1U '1_A 'IQ_N <br /> State any problems not previously meted <br /> 8 . F-O L 1LTION Dr i STTy <br /> Appx. No . People per rq . mi . <br />