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NOTE: PULL ALL PERM-l'S (SEPTIC, WELL, ETC...) N--.,i KE COPIES FOR FILE <br /> LAND USE REPORT APP# Llq- -00- !23 <br /> EHD RECEIVED APP.REFERRAL: a o� COMPLETE& SUBMIT BY IQ • a,f -Uy <br /> BATE DATE <br /> ATTN: k e-a n n e (O ue e /' - <br /> SITE ADDRESS:_07 G(200 (f ISA e- /-�Inr. i, ;nd /rj <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 densi , location of house, wind direction, etc.... <br /> Public water: IV& - Public sewage: <br /> SUMMARY OR COMMENTS: <br /> I recommend: Approval Denial Continuance Inspector's Signature <br /> Supervisor/Lead Senior Comments: <br /> C <br /> ILI <br /> qJ <br /> 9 I1 C' <br /> SUPERVISORILEAD SENIOR APPROVAL: <br /> QA`IIChCECKOFFLIST,`Gr <br /> PTOOsealre ort7ECorreetL4NI)L1,5E#9 <br /> ` = � Correct CQ `DITIDN{S)9 s Logged in-LAND IISE B4©1� <br /> EH 06 06 Rev 1199 y� <br />