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NOTE: PULL ALL'?ERMITS (Septic, Well, etc.) MAKE rOPIES FOR FILE <br /> LAND USE REPORT RECORD ID: SU0004755 <br /> DATE RECEIVED by EHD: December 21,2004 APPL#: PA-04-767 <br /> Referral Agency STAFF CONTACT: KEVIN SWANSON PE : 2632 <br /> SITE APPROVAL-GENERAL(SA) <br /> COMPLETE & SUBMIT BY: yr�(�J(�('t{ q 1 <br /> Assigned to : EE0005366 MEDINA <br /> SITE ADDRESS: 12470 E LOCKE RD, LOCKEFORD APN : 05113212 <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: yU� Public Sewer: <br /> Name of Purveyor Name of System <br /> SUMMARY OR COMMENTS: <br /> I recommend: Approva Denial Continuance Ins ctor: <br /> Signature <br /> Supervisor/Lead Senior COMMENTS: <br /> Q <br /> /- <br /> CZ.1'lvt�e',tnue-- <br /> d ' d <br /> 6/ <br /> SUPERVISOR/LEAD SENIOR Approval: Date: <br /> OA 11 Check OH List: Proofread Report? Correct LAND USE#? <br /> Correct COND`ITION(S)? Logged in LAND USE Book? <br /> EH 06 06 Report 47201 , o tai.. 10.5 Page 4 December 27,2004 <br />