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r <br /> 1 . SEWAG <br /> Distance to Public Sewers Connection necessary: Yes Nom <br /> Does existing septic system comply with Ord. 0549 : Yes 4— No <br /> Unknown If no, explain: <br /> Describe s tic installation to 'be installed: o?oo <br /> 2. WATER SUPPLY <br /> Is water supplied by private well : Yeses No Is well proper: <br /> Yes-Z, No State deficiency: �F <br /> Does existing or porposed use make- this well public water: Yes— <br /> No X <br /> esNomSample of well water tarsen: Yes No_=`::�,, Date tak-e� <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. =. _M O SC)U I TO QB VQ_T_Q PS)'fr i1T I AL <br /> State possible vector potentiftl ?.c necessary control: e��� <br /> 5 . TOILET/BATH FACTTU 'ES <br /> No. & location existing: Additional <br /> facilities needed _ <br /> 6 . PREVInUa op gATIQN HIsTn ; <br /> 7 . QENERAI; SATZTTATION <br /> State any problems not previously noted: <br /> 8 . EOPULATT_nN DENSTIX <br /> Appx. No. People per 6q. mi . <br />