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1 . SEWAGE <br /> Distance to Public Sewers ✓2k Connection necessary : Yes No <br /> Does existing septic system comply with Ord. #549 : Ye0�<— No_ <br /> Unknown If no, explain: <br /> De rbe/ septic ins allation to be installed: 41�4 <br /> 2. WATER SUPPLY <br /> Is water supplied by private well: Yes No Is viell proper: <br /> Yes No State deficiency : <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 ff <br /> 3 . GARBAGE & REEUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <� <br /> 4. FAL MOSQUITQ OR VZ^.TQ ECUI TIAL <br /> State, possible vector potentiftl necessary control: �✓�f <br /> 5 . TQILET/BATH FACILITES <br /> No. & location existing: '��—Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTORY- <br /> 7 . <br /> ISTO r7 . GENERAL SA 111A1' ON <br /> State any problems not previously noted: –';P�1-0'f <br /> 8 . EOPULATT_ON DENSITY / <br /> Appx. No . People per 6q. mi . ���t� �d�.�F <br />