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l• 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. WATER SUPPLY <br /> Is water supplied by private well: Yes No Is well proper: <br /> Yes-Z No State deficiency: <br /> Does a fisting or porposed use make this well public Water: Yes— <br /> No L.- Sample <br /> esNoSample of well water taken: Yes Nov Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> Licenaed scavenger pick-up: Yes— No Service Area No. <br /> Other proposed dispo ale�hod: <br /> pt_ i r,.ahl,em , i1�l,r ,L�r' t <` .. v` �� 9 <br /> 4. FLY. MOSQUITO OR Vj'QTOR PQ'[ENTIAL <br /> State possible vector potentirel 8c necessary control: <br /> 5 . T ILET/BATH FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVTOnS O BRAT ON HISTORX _� / ✓ /� �,. <br /> 12 <br /> 7 . GENERAL SANITA'r ON <br /> State any problems not previously ted: <br /> 3 . POPULATION RUST <br /> Appx. No. People per aq. mi . �] / <br />