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1 . SEWAGE <br /> Distance to Public Sewers zxX 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 . WATER SUPPLY <br /> Isw ter supplied by private well: Yes _K— No Is dell proper: <br /> Yes . No State deficiency :, ���� <br /> Does existing or porposed use make this well public water: Yes <br /> No_L_ Sample of well water taken: Yes No .i 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. FAL MOSQUITO 0$ Vl._T zci'frNT�____IAL_ <br /> State possible vector potentiftl PA necessary control : ­ <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HIST=( <br /> 7 . GENERAL SAPZI'r,A'J'ION <br /> State any problem: not previously noted: <br /> 8 . POPULATION DENSITY zr <br /> Appx. No . People per rq . mi.; <br />