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f <br /> 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 /> s <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 Water: `les <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFM <br /> Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem- <br /> 4. <br /> roblem:4. FLY, MOSQU]IQ OR YCGTOR ESQ�ENTIAL <br /> State possible vector potential 8.c necessary control: <br /> 5 . O <br /> No. & location existing: Additional <br /> facilities needed <br /> 6. ERRYTOna OPERATTQN HISTORY <br /> 7 . GENERAL.SANTTtl ION <br /> State any problems not previously noted: <br /> 8 . POPULATTON DENSITY <br /> Appx. No . People per .aq. mi. <br />