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NOTE: PULL ALL rkrcMITS (Septic, Well, etc.) MAKE--%;&r-4ES FOR FILE. <br /> LAND USE REPORT RECORD ID: SU0004941 <br /> DATE RECEIVED by EHD: March 23,2005 APPL#: PA-05-105 <br /> Referral Agency STAFF CONTACT: J M-R . <br /> LOT LINE ADJUSTMENT(LA)PE : 2690 <br /> COMPLETE&SUBMIT BY: ������-b <br /> Assigned to : EEO005366 MEDINA <br /> SITE ADDRESS: 21905 E ST RT 12 HWY, CLEMENTS APN: 02310024,26,& <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 Continuance Inspector: <br /> Signature <br /> Sut)ervisor/Lead Senior COMMENTS: <br /> SUPERVISOR I LEAD SENIOR Approval: Date: <br /> OA 11 Check Off List: Proofread Report? Correct LAND USE#? <br /> Correct CONDITION(S)? Logged in LAND USE Book? <br /> EH 06 06 Report#7201 Page 5 March 24,2005 <br />