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- _ ME <br /> NOTE: PULL ALL PER1Vrrf S (SEPTIC, WELL, ETC...) N KE COPIES FOR FILE <br /> GLAND USE REPORT APP# f�A- -03 - ° FCMS, <br /> EHD RECEIVED APP-REFERRAL: COMPLE'T'E & SUBMIT BY <br /> DA ' r DATE <br /> ATTN: '� G��/�f 7 <br /> SITE ADDRESS: - 4 LQEM(7L 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: <br /> SUMMARY OR COMMENTS: <br /> ALL <br /> /=ZV2. *h:;160.C4 W <br /> c4c Ar,� ee�lL Ci�yS►�/.e� <br /> C` ! �< <br /> a <br /> lzmw <br /> I recommend: Approval Denial Continuance Inspector's Signatu - _ <br /> Is$$e ie is is it is is 9s is�c is 9r�e Lexie x�F�c 9s aY kzs$s is 3c 9skirxie xis is is�F�c it is is 9e it isx kis is kis is�F is do is do of is is ieK�kx:F is is is is is�E�F it iexxie Jc it is it is is is$c vex9e irx <br /> Supervisor/Lead Senior Comments: <br /> - <br /> C�. .a : o ;)L- <br /> n <br /> ~ al <br /> SUPERVISORILEAD SENIOR APPROVAL: <br /> �'OA II CHECK OFF LIST'' g Proofread report? " ' Carred L:9ND tISE#? <br /> EH 66 06 Rev 1199 ' <br /> Correct CDNDITION(SJ p I egged in LAND USE BOOK? <br /> s. <br />