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L6 <br /> NOTE: PULL ALL PERMrfS (SEPTIC, WELL, ETC...) N1-!0.KE COPIES FOR FILE <br /> LAND USE REPORT APP# -5114 - 00- d' a <br /> EHD RECEIVED APP.REFERRAL: /,� —/ yJ COMPLETE & SUBMIT BY /,Z- 39-0' <br /> DATE DATE <br /> ATTN: n eA <br /> SITE ADDRESS: Z,7 C p e-�'-t <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 /> !A.�,�,. # dna - <br /> I recommend: Approval Denial Continuance Inspector's Signature <br /> x*eYx�cie�E�k�Fiex�cie4eicF�F9c9c�FicF*�F*�cxicxicic�raF�'c9cic�c'c*�Fic*ic*�c�Ficicic*4c*�'c*�cieicnEicic9c�'c�c�4�kieicirie�F*�c�F�r�c9c�c�c�e�rir9cic9c*ic�cFazic <br /> Supervisor/Lead Senior Comments: <br /> SUPERVISOR/LEAD SENIOR APPROVAL: <br /> OA II CHECK OFF LIST.• Proofread report? Correct LAND USE#? <br /> EH 06 06 Rev 1/99 Correct CONDITION(S)? Logged in LAND USE BOOK? <br />