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U", <br /> -NOTE: PULL ALL PERl1,,-3 (SEPTIC, WELL, ETC...) '.,�E COPIES FOR FILE <br /> LAND USE REPORT APP# A 8S <br /> EHD RECEIVED APP.REFERRAL: W a kV COMPLETE & SUBMIT BY AM 4 <br /> DATE ff ,^, . __ ,^, , • , (�Q ,, DATE <br /> ATTN: <br /> SITE ADDRESS: <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: Z-20 Public sewage: /JC' <br /> SUMMARY OR COMMENTS: <br /> 4 ,� Zzed <br /> I recommend: Approval Denial Contin ce Inspector's Si nature <br /> Supervisor/Lead Senior Comments: <br /> a -S-/p 93y <br /> C M� r/ • a S ���� SCe <br /> SUPERVISOR(LEAD SENIOR APPROVAL: <br /> OA H CHECKOFF LIST: _Proofread report? Correct LAND USE#? <br /> EH 06 06 Rev 1/99 _Correct CONDITION(S)? Logged is LAND USE BOOK? <br />