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NOTE: PULL ALL 4-cRMITS (Septic, Well, etc.) MAKE ,_,_,PIES FOR FILE <br /> LAND USE REPORT RECORD ID: S00004516 <br /> DATE RECEIVED by EHD: June 15,2004 APPL#: PA-03-232 <br /> Referral Agency STAFF CONTACT: RAYMOND HOO PE : 2631 <br /> SITE APPROVAL-MINOR(SA) <br /> COMPLETE& SUBMIT BY: Tue, July 6, 2004 Assigned to : EE0005366 MEDINA <br /> SITE ADDRESS: 22550 N THIRD ST, CLEMENTS APN : 01924051 <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: C ���' jy , Public Sewer: end <br /> Name of Purveyor Name of System <br /> SUMMARY OR COMMENTS: <br /> JYX 4 <br /> I recommend: Approval Denial F-1 Continuance ❑ or: <br /> Signature <br /> Supervisor/Lead Senior COMMENTS: <br /> oS <br /> • /0 <br /> C <br /> SUPERVISOR/LEAD SENIOR Approval: '�-'� - Date: <br /> OA 11 Check Off List: Proofread Report? Correct LAND USE#? <br /> Correct CONDITIONS)? Logged in LAND USE Book? <br /> EH 06 06 Report#7201 Page 3 June 22,2004 <br />