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5� 338x3 ssc �l� Lm ., <br /> NOTE: PULL ALL PERK -S (SEPTIC, WELL, ETC...) f _ rKE COPIES FOR FILE <br /> y�T <br /> LAND USE REPORT APP# <br /> EHD RECEIVED APP.REFERRAL: COMPLETE & SUBMIT BY <br /> DAT DATE <br /> ATTN: tow <br /> SITE ADDRESS: i 57n q 4.0 T Ck/, <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: /l27 Public sewage: e: � <br /> SUMMARY OR COMMENTS: <br /> or/ <br /> �� cYI r <br /> I recommend: Approval Denial Continuance Inspector's Signature 7L <br /> �F�'c 9cX*�F is icxxx>cx>c�c 9c 7c cx�c Fzxir is is is*xic Fxxis irxicxx*xic icxzzx�c 7c�cxxicx is is�c�cxxacxxicxxxis>cxx�c 4c�c�r'xxzxxx xxxic 7c�c is <br /> Supervisor/Lead Senior Comments: <br /> C)ft 3 ° <br /> r <br /> a. <br /> C. <br /> a `I - - ,C► ,t�.f .. P`IPS=►wJ 4C41 �a !Y'�y/1� =' _` 4�Q�1' J- <br /> V <br /> ctr <br /> SUPERVISOR/LEAD SENIOR APPROVAL: - ? 9-///0- <br /> Olt ), OA II CHECKOFF LIST: Proofread report? Correct LAND USE#? <br /> EH 06 06 Rev 1/99 Yn � 6 Correct CONDITION(S)? Logged in LAND USE BOOK? <br /> ^dam <br />