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NOTE: PULL ALL4'VERMITS (Septic, Well, eta.) MAKE',.JPIES FOR FILE <br /> LAND USE REPORT RECORD ID: SU0003425 <br /> DATE RECEIVED by EHD: April 13,2004 APPL#: PA-04-180 <br /> Referral Agency STAFF CONTACT: JENNIFER JOLLEY PE : 2626 <br /> USE PERMIT-GENERAL(UP) <br /> COMPLETE&SUBMIT BY: Wed, April 28, 2004 Assigned to : EE0005366 MEDINA <br /> SITE ADDRESS: 16750 E 5T RT 88 HWY,LOCKEFORD APN: 01918035 <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 /> -. <br /> j-.� ?-1)J5-. ?- <br /> I rec mmend: Approval ❑ Denial F Continuance Inspector: <br /> Signature <br /> Su ervisorlLead Senior COMMENTS: <br /> 0 u <br /> Ji <br /> Y�43 HA2`[.-I'�`" f✓' � � w a.. �'Yf <br /> SUP RVISOR I LEAD SENIOR Approval: Date: <br /> OA ilCheck Off List: Proofread Report? Correct LAND USE#? <br /> Correct CONDITION(S)? Logged in LAND USE Book? <br /> Q <br /> EH 06 06 Repo 7201 <br /> � Page 1 April l6,200 <br /> h���'L►/t//f�`,per <br />