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NOTE: PULL ALL PERMITS (SEPTIC, WELL, ETC...) MAKE COPIES FOR FILE <br /> LAND USE REPORT APP# _514 - 99 -3✓ <br /> EHD RECEIVED.APP.REFERRAL: COMPLETE & SUBMIT BY (O - <br /> DATE n� // / DATE <br /> ATTN: /�a q* i'/SAe r' <br /> SITE ADDRESS: 110119 N , / n/JL l SDC Z6A V ,�t �d . L.:)CI <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: A t^ Public sewage: Ij (/- <br /> SUMMARY OR COMMENTS: <br /> S.�3s�"r '� "nc� FvtrtrOwriy(r GOr� � Tiv S <br /> �>Siyt��'/T G{9�Gvs�� �LLvS7'�'� TIr � F�CALT /�OGg7'/ p/l <br /> 0sajLoG1�♦p O� ICtSTr SYS <br /> cxPt�s= RGr �� e <br /> STATE' <br /> [ recommend: Approval Denial Continuance Inspector's Signature <br /> Supervisor/Lead Senior Comments: <br /> SUPERVISOR/LEAD SENIOR APPROVAL: <br /> OA 11 CHECKOFF LIST. --�Proojread �rrec/LAND USE#? <br /> EH 06 06 Rev 1/99 Correct CONDITION(S)?report?Logged in LAND USE BOOB? <br />