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NOTE: PULL ALL%wdRMITS (Septic, Well, etc.) MAKE*JPIES FOR FILE <br /> LAND USE REPORT RECORD tD: SU0004701 <br /> DATE RECEIVED by EHD: November 09,2004 APPL#: PA-04-61 <br /> Referral Agency STAFF CONTACT: RICK GRIFFIN PE : 2631 11 <br /> SITE APPROVAL-MINOR(SA) <br /> COMPLETE& SUBMIT BY: Wed, December 1, 2004 <br /> Assigned to : EE0005366 MEDINA <br /> SITE ADDRESS: 12899 E LOCKE RD,LOCKEFORD APN : 05129027 <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: IV7-n Public Sewer: <br /> Name of Purveyor Name of System <br /> SUMMARY OR COMMENTS: <br /> U <br /> I recommend: Approv Denial ❑ Continuance El Ins ecto <br /> Si nature <br /> Supervisor/Lead Senior COMMENTS: <br /> /1 rA <br /> SUPERVISOR/ LEAD SENIOR Approval: Dale: <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 I November 17.22004 <br />