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'= NOTE: PULL ALLk- :RMITS (Septic, Well, etc.) MAKE ' P <br /> LAND <br /> FOR FILE + <br /> a" <br /> LAND USE REPORT RECORD ID: SU0004660 <br /> DATE RECEIVED by EHD: October 04,2004 APPL#: PA-04-539 <br /> Referral Agency STAFF CONTACT: GILLIAN HAYES PE : 2631 <br /> SITE APPROVAL-MINOR(SA) <br /> COMPLETE& SUBMIT BY: Tue, October 19, 2004 <br /> Assigned to • EE0005366 MEDINA <br /> SITE ADDRESS: 18500 N ST RT 88 HWY, LOCKEFORD APN : 05131007 <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 /> ame of Purveyor Name of System <br /> SUMMARY C MENT <br /> z e <br /> / f <br /> 'J <br /> I recommend: Approval Denial ContinuanceEl <br /> In pector• ,,- <br /> Sig ature <br /> Su ervisor/Lead Senior COM ENTS: <br /> e <br /> qi <br /> I <br /> 1 <br /> SUPERVISOR 1 LEAD SENIOR Approval: Date: <br /> E!Check Off List: Proofread.Report?.. Correct LAND USE#? <br /> Correct CONDITION(S)7 Logged in LAND USE Book?; <br /> X06 06 Report 97201 Page 8 October 08,2004 <br />