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leC <br /> NOTIE: PULL ALL PERMh*5 (SEPTIC, WELL, ETC...) M�.." COPIES FOR FILE <br /> LAND USE REPORT APP# 5A "'UO- 7 y <br /> EHD RECEIVED APP.REFERRAL: 19 -Y 4 Q wV COMPLETE & SUBMIT BY I — .3 - O � <br /> DATE /' / DATE <br /> ATTN: J e �r �l Sh e <br /> SITE ADDRESS: .30 1 E am P d <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 <br /> ''dII ens ty, location of house, wind direction, etc.... <br /> I <br /> Public water: o Public sewage: , <br /> SUMMARY OR COMMENTS: <br /> I recommend: Approval Denial Continuance Inspector's Signature <br /> Supervisor/Lead Senior Comments: <br /> 1107 <br /> oy <br /> 11 : 6 <br /> S <br /> SUPERVISOR/LEAD SENIOR APPROVAL: <br /> OA Il CHECK OFF LIST. Proofread report? Correct LAND USE ti? <br /> EH 06 06 Rev 1/99 Correct CONDITION(S)? Logged in LAND USE BOOK? <br />