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SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes No_, <br /> Does existing septic system comply with Ord. #549 : Yea 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 No State deficiency: <br /> Does existing or porposed use make this well public crater: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . <br /> Licensed scavenger pick-up: Yea No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY. MOSQUITO QR VECTOR Pn'rrU� T1AL- <br /> State possible vector potenti¢cl & necessary control: <br /> 5. TOILET/BATH-FACILITES <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. PREVIQUS OPERATI!DH HTSTORX <br /> 7 . <br /> State any problems not previously noted: <br /> S . POPULATTDN DRUSITY <br /> Appx. No. People per eq. mi. <br />