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NOTE: PULL ALL PERMITS (SEPTIC, WELL, ETC...) MAKE COPIES FOR FILE <br /> LAND USE REPORT APP# <br /> EHD RECEIVED APP.REFERRAL: V —f 47 —v"_ COMPLETE & SUBMIT BY <br /> DATE qq DATE <br /> ATTN: <br /> SITE ADDRESS: n'7 � ' •�1� "AL «•a L_ � c�'�,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: r - <br /> SUMMARY OR COMMENTS: <br /> 0 <br /> I recommend: Approval Denial Continuance Inspector's Signatur <br /> Supervisor/Lead Senior Comments: <br /> SUPERVISORILEAD SENIOR APPROVAL: <br /> UA:II CHECK Uri*'LIST X50 aPrao rears rey'yard? � � Gnrrecl LAND CISE#' Y <br /> s� <br /> EH 06 06 Rev u99 €Correct Q1VD Uoxm-?, N� Lagged L 4"USLP'BOOK? <br />