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{ T111. <br /> Nfl�TE: PULL ALL PERK S (SEPTIC, WELL, ETC...) ; ✓,KE COPIES FOR FILE <br /> LAND USE REPORT APP# —QI"fes <br /> e. <br /> EHD RECEIVED APP.REFERRAL: —oZ4'�� COMPLETE & SUBMIT BY <br /> DATE <br /> ATTN: nSITE ADDRESS: ;2 SR} Q— /V <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 /> Cilc An Q <br /> AO <br /> .eI <br /> GG .� <br /> I recommend: Approval Denial Continuance Inspector's Signature <br /> Supervisor/Lead Senior Comments: <br /> IV V <br /> �r <br /> X� A <br /> 4 O - -ziqR i <br /> SUPERVISOR/LEAD SENIOR APPROVAL: <br /> II.CH frK OFFIIST ;`_ 'Proofread report?Y' a° Correct LAND tISE V,-` <br /> EJ-1 06 06 Rev 1/99 Correct CONDITION(S)7 Logged in LAND USE BOOK? <br />