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S <br /> NOTE: PULL ALL* .RMITS (Septic, Well, etc.) MAKE,_�'oIES FOR FILE <br /> LAND USE REPORT RECORD ID: SU0004558 <br /> DATE RECEIVED by EHD: July 13,2004 APPL 4: PA-04-372 <br /> Referral Agency STAFF CONTACT: JOHN FUNDERBURG PE : 2690 <br /> LOT HNE ADJUSTMENT(LA) <br /> COMPLETE& SUBMIT BY: <br /> A eq A P VJL- <br /> = <br /> P V --Df) <br /> I t%or 11 _W I e Assigned to : EE0005366.1MEDINA <br /> SITE ADDRESS: 7521 E STATE ROUTE 12 HWY, NODI APN : 05103073& 80 <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: <br /> Public Sewer: <br /> Name of Purveyor Name of System <br /> SUMMARY OR COMMENTS: <br /> Q� <br /> I recommend: Approval Denial Continuance Ins ector: <br /> Si ature <br /> Supervisor/Lead Senior COMMENTS: <br /> SUPERVISOR 1 LEAD SENIOR Approval: Date: <br /> OA�'!J"Cb�c'k Off List Correct CONDITION 7 � � :,Logged,Cosrect LAND.USE#2 <br /> ` ,Proofread- ort7 <br /> m T <br /> .� iln�LAND USE BooO <br /> E EH 06 06 Report#7201 Page 5 Juty 16,2004 <br />