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NOTE: PULL ALL P ITS (Septic, Well, etc.) MAKE C S FOR FILE <br /> LAND USE REPORT RECORD ID: SU0004869 <br /> DATE RECEIVED by EAD: March 01,2005 APPL#: PA-05-99 <br /> Referral Agency STAFF CONTACT: RICK GRIFFIN PE : 2631 <br /> STFE APPROVAL-MINOR(SA) <br /> COMPLETE&SUBMIT BY: Tue, March 22, 2005 <br /> Assigned to: EE0005366 MEDINA <br /> SITE ADDRESS: 21802 N ST RT 99 RD,ACAMIPO APN: 01704015 <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 ofhouse,wind direction, etc.... <br /> Public Water: Public Sewer: <br /> Name of Purveyor Name of System <br /> SUMMARY OR COMMENTS: c �� <br /> I recommend: Approval =Denial Continuance ❑ Inspe or: <br /> Signa <br /> ttre I <br /> Supervisor/Lead Senior COMMENTS: <br /> SUPERVISOR/LEAD SENIOR Approval: Date: O O <br /> OA 11 Check Off List Proofread Report? AV Correct LAND USE#? <br /> Correct CONDITION(S)? Logged in LAND USE Book? <br /> EH 06 06 Report 47201 Page 10 Much 02,2005 <br />