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1 . 9FWA3F� <br /> Distance to Public Sewers ^'''�� Connection necessary: Yes No4 <br /> Does exi ting 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 +- /iso Is well proper: <br /> Yes No State deficiency : <br /> Poe "a-c&St r C s' cY&c,-of r a &,,e/J roe s <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 <br /> 3 . RFFUSF <br /> Licensed scavenger pick-up: Yes No Service Ar No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . FL L MOSQUI`IQ QR V QTO PSfTI�TI <br /> State possible vector potentiftl & necessa control : <br /> 5 . TOILFT/BATH FACILITES <br /> No. ez location, existing: Additional <br /> facilities needed- <br /> 6 . <br /> eeded6 . PRE,y_TOUS OPERAT ON HI ATO <br /> J <br /> 7 . GENERAL SAP 'r " <br /> State any prob /ems not previously noted : _ <br /> Appx. o . People per rq. rni . <br />