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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 . VATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Yes No State deficiency : <br /> Does existing or porposed use make this well public water: Yes <br /> No _ Sample of wall water taken, Yes No Date taken <br /> Results Additional information or comments <br /> 3 . AGE & REFUSE <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem.--_ <br /> 4. FLY. MOSQUITO OA VEQTQQR Pff NTTAL, <br /> State possible vector potentiftl FA necessary control: <br /> 5 . TOr_L,ETIBATH, I9_�1c,ILITF.� <br /> No. ec locution existing : Additional <br /> facilities needed <br /> 6 . PREYTOUS Q R TTON HISTORY <br /> 7 . GENERAL �S,ANIJATTn <br /> State any problems not Previously noted: <br /> S • PQE'.ULA jST v <br /> Appx. No. People per coq mi . <br />