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NOTE: PULL ALL PERM!x fS (SEPTIC, WELL, ETC...) .-,eAKE COPIES FOR FILE <br /> LAND USE REPORT APP# 5 <br /> EHD RECEIVED APP.REFERRAL: I —Q- A—Q�-- COMPLETE & SUBMIT BY l —1 <br /> DATE DATE <br /> ATTN: I <br /> SITE ADDRESS: �� f—�. �—• �-� / '� .�- ,� ) r 1n._fv� <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 /> I recommend: Approval Denial Continuance Inspector's Signature <br /> *nk�c*�Y�e�cx4c�cx�'cicx3rdcX�c**x�c*lc�cx�c�'r�c4c�cx�crr�"c�cx�cxicX*�cakx*9rak�'c�F�c*�c**x4c*x�cnEa'cx9c4e�c�c9c*�c�c7erc��cisisdoacxacx�c�Fxx�cx�c9e <br /> Supervisor/Lead Senior Comments: <br /> ,f <br /> SUPERVISOR/LEAD SENIOR APPROVAL: l' <br /> OA II CHECKOFF LIST. Proofread report? Correct LAND USE#? <br /> EH 06 06 Rev 1/99 Correct CONDITION(S)? Logged in LAND USE BOOK? <br />