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NOTE: PULL ALLa..RMITS (Septic, Well, etc.) MAKE �,PIES FOR FILE <br /> LAND USE REPORT RECORD ID: SU0004557 <br /> DATE RECEIVED by EHD: July 13,2004 APPL#: PA-04-363 <br /> Referral Agency STAFF CONTACT: GILLIAN HAYES PE : 2622 <br /> SIIBDIVISON-MINOR(MS) <br /> COMPLETE& SUBMIT BY: Tue, August 3, 2004 <br /> Assigned to : EE0005366 MEDINA <br /> SITE ADDRESS: 21850 E LIBERTY RD, CLEMENTS APN : 02120022 <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: A-X <br /> Name of Purveyor Name of System <br /> SUMMARY OR COMMENTS: <br /> C <br /> aa. od <br /> / C <br /> // <br /> aa.'Ci <br /> i5 n i <br /> I recommend: ApprovaI Denial El Continuance El Inspe <br /> Sign tore <br /> Supervisor/Lead Senior COMMENTS: <br /> Q LS <br /> ' d7 ✓ ✓ <br /> O / <br /> : s3 rJ a0 � S <br /> r d <br /> s �. <br /> a <br /> SUPERVISOR/LEAD SENIOR Approval: Date: <br /> OA 11 Check OH List: Proofread Report? Correct LAND USE#? <br /> Correct CONDITION(S)? Logged in'LAND USE Book? <br /> EH 06 06 Report#7201 Page 4 July 16,2004 <br />