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] . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes.L No_ <br /> Does existing septic system comply with Ord. #549 : Yes No_.,_. <br /> Unknown If no, explain: <br /> f q .1 G[ <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: Yes <br /> No Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . QARBAQE & REFUSE <br /> . Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4 . -MOSQUITO OR VECTOR FC)MMAL. <br /> State possible vector potential. & necessary control : <br /> 5 . Tgr-16CMIM <br /> No. & location existing : __ Additional <br /> facilities needed <br /> 6 . HISTORY <br /> 7. GENEBAL 5 M <br /> State any problems not previously noted-- _ <br /> g . EUULATIQN DENaITom' <br /> Appx. No. People per sq. mi . <br />