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r NOTE: PULL ALL P-iRMITS (Septic, Well, etc.) MAKE '-.jIES FOR FILE <br /> LAND USE REPORT RECORD ID: SU0004655 <br /> DATE RECEIVED by EHD: October 07,2004 APPL#: PA-04-572 <br /> Referral Agency STAFF CONTACT: GILLIAN HAYES PE : 2690 <br /> LOT LINE ADJUSTMENT(LA) <br /> COMPLETE& SUBMIT BY: � � �j <br /> r Assigned to • EE0005366 MEDINA <br /> SITE ADDRESS: 19003 N ST RT 88 HWY, LOCKEFORD APN : 05130012, 13& <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 F-1 Continuance F-1 Inspector: <br /> Signature <br /> isorlLe Senior COMMENTS: <br /> SUPERVISOR 1 LEAD SENIOR Approval: Date: <br /> OA A Chec-OfiFtist, roofread Rep�ri . a e t LANv— SE 7 <br /> Correct C NDITtON(S)7 Logged in,LANl—... Book?._... . <br /> EH 06 06 Report#7201 Page 3 October 08,2004 <br />