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NOTE: PULL ALL PERN�,,'S (SEPTIC, WELL, ETC...) I KE COPIES FOR FILE <br /> /Q,,�7/_ <br /> LAND USE REPORT APP# M5 -9 � -/ 3 y� cc <br /> EHD RECEIVED APP.REFERRAL:, -D-0-01 COMPLETE & SUBMIT BY <br /> DATE DATE <br /> ATTN: OwdLL f'l a(fin <br /> SITE ADDRESS: qq i n E 6 Jai , 540c_,(c_fyr` <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, cation of house, wind direction,etc.... / <br /> Public water: Public sewage: ✓/ % <br /> SUMMARY OR COMMENTS: <br /> Cr-if 00 , <br /> ZZ -30 <br /> I recommend: Approval Denial Continuance Inspector's Signature <br /> Supervisor/Lead Senior Comments: <br /> � I <br /> t.cn�.�/� <br /> a.� V <br /> SUPERVISOR/LEAD SENIOR APPROVAL, <br /> OA Il CHECK OFF LIST.• Proofread report? Correct LAND USE#? <br /> EH 06 06 Rev 1199 _Correct CONDITION(S)? Logged in LAND USE BOOK? <br />