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NOTE: `PULL ALL PERI 'S (SEPTIC, WELL, ETC...) *KE COPIES FOR FILE <br /> LAND USE REPORT APP# f;d -O l -3 O <br /> EHD RECEIVED APP.REFERRAL: ` —10 v U( COMPLETE & SUBMIT BY -5 - 9 —() / <br /> DATE I [SATE <br /> ATTN: ----p�,voz— ` `�,�,, '�j e- <br /> SITE ADDRESS: a ( 3 S [-� [Al C .r)- )Cd • , -i- tli <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: Y 0 Public sewage: <br /> SUMMARY OR COMMENTS: <br /> 2U 0 <br /> Continuance Ins <br /> I recommend: Approval Denial ector's Signature P <br /> $r ex*�k�i�i�e9c9c �c icix�e*�c*fie *�r*ic�kicdc�e3c3e�Y*x*�c�F�Yicie9c�cic*�Ficiciviric4r�c3cie�crc icivieicxie*$cic�c�e*fir*�cie�e9eicdc�F�ciric'1 xieiexx <br /> Supervisor/Lead Senior Comments: <br /> 0 / <br /> 14-. o -A- - <br /> SUPERVISOR/LEAD SENIOR APPROVAL: <br /> OA II CHECK OFF LIST: Proofread report? Correct LAND USE V <br /> EH 06 06 Rev 1/99 Correct CONDITION, M? Logged in LAND USE BOOK? <br />