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NOTE: PULL ALL P ITS (Septic, Well, etc.) MAKE C ES FOR FILE <br /> LAND USE REPORT RECORD ID: SU0004907 <br /> DATE RECEIVED by EHD: March 15,2005 APPL#: PA-05-116 <br /> Referral Agency STAFF CONTACT: JOHN FUNDERBURG PE : 2633 <br /> COMPLETE&SUBMIT BY: Wed, March 30, 2005 SITE APPROVAL-MAJOR(SA) <br /> Assigned to : EE0005366 MEDINA ' <br /> SITE ADDRESS: 26590 N SACRAMENTO AVE, THORNTON APN: 00122032 <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 /> SupervisorLLead Senior COMMENTS: Signature <br /> t � <br /> 60 <br /> SUPERVISOR/LEAD SENIOR Approval: Date: <br /> OA H Check Off List_ Proofread Report? Correct LAND USE#? <br /> Correct CONDITION(S)? Logged in LAND USE Book? <br /> EH 06 06 Report#7201 Page 2 March 16,2005 <br />