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4 17 " ' <br /> L Y y � <br /> i. f NOTE: PULL ALLY-.-ERMITS (Septic, Well, etc.) MAKE COPIES FOR FILE <br /> LAND USE REPORT RECORD ID: SU0004626 <br /> DATE RECEIVED by EHD: August 30,2004 APPL#: PA-04-479 <br /> Referral Agency STAFF CONTACT: JOHN FUNDERBURG PE : 2631 <br /> SITE APPROVAL-MINOR(SA) <br /> COMPLETE&SUBMIT BY: Tue, September 21, 2004 <br /> Assigned to : EE0000149 BORGES <br /> SITE ADDRESS: 120 W ACAMPO RD, ACAMPO � r , APN : 0I312001 <br /> In completing the Land Use investigation, draw all Public Health factors on the exhibit(i.e., sewage disposal, water <br /> supplies, etc...). Where necessary, on an attached piece of plain paper, draw complete map of area showing population <br /> density, location of house, wind direction, etc.... <br /> Public Water: Public Sewer: <br /> Name of Purveyor Name of System <br /> SUMMARY OR COMMENTS: <br /> I recommend: Approval ❑ Denial ❑ Continuance Inspector: <br /> Signature <br /> Supervisor/Lead <br /> �rSenior COMMENTS: <br /> ICJ V. /I � .4 <br /> 4a 0--,� AzaALAOL <br /> SUPERVISOR 1 LEAD SENIOR Approval: Date: <br /> Proofread RN S ? : Correct>AND Ci SE#1? T <br /> OAIh6hsckOffLFst: P ��:.. r <br /> =' Correct CONPJ C O Logged in LAN1 [SSE=Baok? <br /> EH 06 06 Report#7201 Page 6 September 02,2004 <br />