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NOTE: PULL ALL PERMITS (SEPTIC, WELL, ETC...) <br /> Ivt-AKE COPIES FOR FILE <br /> LAND USE REPORT <br /> APP# <br /> )/ g <br /> Ek��RECEIVED APP.REFERRAL: r v COMPLETE & SUBMIT BY DATE <br /> DATE <br /> ATTN: S <br /> SITE ADDRESS: <br /> In g com letin the Land Use investigation, draw all Public Health factorso eche aw factors <br /> lmple . sewage map lisp asal, <br /> p <br /> water supplies, etc...). Where necessary, on an attached piece of plain paper, <br /> ap <br /> showing population density, location of house,wind direction, etc.... <br /> Public sewage: <br /> Public water: <br /> SUMMARY OR COMMENTS: <br /> I recommend: Approval <br /> Denial Continuance Inspector's Signature <br /> Supervisor/Lead Senior Comments- <br /> SUPERVISOR/LEAD SENIOR APPROVAL: <br /> Ot!II CHECKOFF LIST Proofread reports °'Correct LAiVD USE# <br /> � " <br /> BODK � <br /> EI-1 06 06 Rev 1199 <br />