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x-14 0-te... P&I rN- J am,-, 7/-fit e c <br /> NOTE: PULL ALL PERMITS (SEPTIC, WELL, ETC...) AKE COPIES FOR FILE <br /> LAND USE REPORT APP# -n1- <br /> FIID RECEIVED APP.REFERRAL: W - COMPLETE & SUBMIT BY . lq r I 6 `J -01 <br /> DATE DATE <br /> ATTN: Lrlcl ),6.We�ce <br /> SITE ADDRESS: ,y -r <br /> In completing the Land Use investigation, draw all Public Health factors on the exhibit (i.e.: sewage disposal, <br /> water supplies, etc...). Where necessary, on an attached piece of plain paper, draw completed map of area <br /> showing population density, location of house, wind direction, etc.... <br /> Public water: Public sewage: <br /> SUMMARY OR COMMENTS: <br /> OF <br /> I recommend: Approval—Z Denial Continuance Inspector's Signature <br /> Supervisor/Lead Senior Comments: <br /> i <br /> I' <br /> i <br /> SUPERVISOR/LEAD SENIOR APPROVAL: c> <br /> OXlk-CHECK' LIQ _r. �frvofread reponf? Correct Lf1ND'USEW# <br /> EH 06 06 Rev 1194 ` t Trect CQio-N���JITIQN(S):' Logg'e'd}n,. :AND USE BO oKq <br />