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`sa,3 <br /> NOTE: PULL ALL PERI%---r TS (SEPTIC, WELL, ETC...) r SAKE COPIES FOR FILE <br /> LAND USE REPORT APP# PA - 0 -�3�lSfl /10" <br /> EHD RECEIVED APP.REFERRAL: ) COMPLETE & SUBMIT BY GC/ 1//a3 <br /> DAT ATE <br /> ATTN: 2 LJ I r1 FS <br /> SITE ADDRESS: o2 ,a SSU Ni . - <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 /> t �= X0 <br /> /'(-.1..//• /�.�3iP.._x .f°r r,�r� r s �'li< i��.� <br /> // �� `-�' }/' � f-'r (- ��'!7. (''•x✓''!%i7 G"'s') �.�'`'✓ `�lx l�''..aF '^} '/.. -'a.s' '7/L� � ,-y�. ,�/-�`x' �, -`i-�Nr ,/�'. <br /> I recommend: Approval Denial Continuance Inspector's Signat a "_ <br /> Supe or/Lead Senior Comments: <br /> Viisa. <br /> zn <br /> 4' cxld x :� <br /> rC <br /> i �� : �,�,��-,�-1 ,rd-Q,+.ay�.+�� 4�r �r�„�j C✓�� �+�lk�t $i <br /> � F1 <br /> SUPERVI OR/LEAD SENIOR APPROVAL: <br /> V E�- OA H CHECK OFF LIST.• Proofread report? Correct LAND USE#? <br /> EH 06 06 Rev 1199 Correct CONDITION(S)? Logged in LAND USE BOOK? <br /> •c,�.onwif� ,��j, est; <br />