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NOTE: PULL ALL PERNrITS (SEPTIC, WELL, ETC...) MAKE COPIES FOR FILE <br /> LAND USE REPORT APP# -5A - �! q- 27 <br /> EHD RECEIVED APP.REFERRAL: /0-5— //7 COMPLETE & SUBMIT BY /() —/ g — 9c? <br /> DATE DATE <br /> ATTN: e F_5 Je r <br /> SITE ADDRESS: I 1J1 (�i�) , d cl , Road . /q ck rri P o <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: r Public sewage: N6&)U <br /> SUMMARY OR COMMENTS: <br /> Ci - o(, <br /> / 6 a - -- Q <br /> Ll V <br /> I recommend: Approval Denial Continuance Inspector's Signatuve'�� IAZ 04�, � <br /> Supervisor/Lead Senior Comments: <br /> SUPERVISOR/LEAD SENIOR APPROVAL: <br /> OA II CHECK OFF LIST.• Proofread report? Correct LAND USE#? <br /> EH 06 06 Rev 1/199 Correct CONDITION(S)? Logged in LA.VD USE BOOK? <br />