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NOTE: PULL ALL PERM-.*'S (SEPTIC, WELL, ETC...) A.AKE COPIES FOR FILE <br /> t <br /> LAND USE REPORT APP# <br /> ,q-sr4 P <br /> EHD RECEIVED APP.REFERRAL: —��44 COMPLETE & SUBMIT BY <br /> DATE DATE <br /> I <br /> SITE ADDRESS: _19 ( � r�4 . T`C1 1 12 �n a(� L.�r,/c�Aoc <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: ce" � y �J <br /> SUMMARY OR COMMENTS: <br /> 'I <br /> I recommend: Approval V Denial Continuance Inspector's Signature <br /> J <br /> Supervisor/Lead Senior Comments: <br /> r � <br /> �I <br /> �I <br /> SUPERVISOR/LEAD SENIOR APPROVAL: <br /> i <br /> 0A II CHECK OFF LIST "-�'��=.x.��Proofread repait? -F �Coriecl I.�ND.Il3E#9 �' <br /> i EH 05 05 Rev 1/99 '� ��% _ Correct CONDITI01 V(S)9 Logged m LA11iD USE BOOK? " <br /> qvii 4...Y-,,....,• '.o-.. '-'>. .x f, t ,a= {$ e;'ku%: <br />