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Km 4 M� <br /> NOTE: PULL ALL PER�.TS (SEPTIC, WELL, ETC...) SAKE COPIES FOR FILE <br /> LA—&D USE REPORT APP# PA - o -jy� <br /> EHD RECEIVED APP.REFERRAL:I COMPLETE & SUBMIT BY <br /> D TE /� ATE <br /> ATTN -R ; r,K A r;AA , <br /> SITE ADDRESS: c2,3() d /I/ h/Ifon <br /> Rd, , (flelnel,2z�5- <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 /> o 9 / <br /> ,,Q-ma�c-e.. <br /> ecommend: Approval Denial Continuance Inspector's Signature <br /> �x,v *�x�*�r���**r*�g�*�***,g�,* **:�+gpv*��**x�,q*,v�**t��:v* �F�xx�tx• ,v tt���*� �r*�,�*�v�v�+�t� <br /> Supervisor/L md Sen ornmeenntts�Y <br /> & // : 03 <br /> VV <br /> _ f .. E- o j <br /> o� (�✓dA4 �' < p � t_ca lCK <br /> Ce � �) � ,2::t _ 4 d fir' <br /> 4411V _,d <br /> SUPERVISOR/LEAD <br /> aSENI6R(/JeJfPPROVAL: <br /> .•,4 <br /> [.— �Qy , <br /> ,"s�^+{�` >"-GL••� •i "SVY.b'C%• :}a .. �'l`��{.. �l<.';:-. /L�, <br /> \s ° o.4E(L 0.4 II CHECK OFF LIST. _Proofread report? _Correct LAND USE#? <br /> H 1 0 RRev 1199 _ Correct CONDITION(S)? _Logged in LAND USE BOOK? <br /> �iy_ /41�i MT' i• <br /> C� Co., 's- li <br />