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NOTE: PULL ALL PERMITS (Septic, Well, etc.) MAKE MIES FOR FILE <br /> LAND USE REPORT RECORD ID: SU0004686 <br /> DATE RECEIVED by EHD: November 02,2004 APPL#: PA-04-608 <br /> Referral Agency STAFF CONTACT: JOHN FUNDERBURG PE : 2632 <br /> SITE APPROVAL-GENERAL(SA) <br /> COMPLETE& SUBMIT BY: Wed, November 10, 2004 <br /> Assigned to : EE0005366 MEDINA <br /> SITE ADDRESS: 11849 E ST RT 12 HWY, LOCKEFORD APN : 05118028 <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 /> ) 7— Glc.Ii7s�sc�i.�i��t r <br /> I recommend: Approva Denial Continuance Insp ctor: 22:7 4929� <br /> Sig ature <br /> Supervisor/Lead Senior COMMENTS: , ,�_ �j� 000 <br /> 4A <br /> �A/-bra-,. <br /> 00 <br /> • ,..,� d <br /> Ab <br /> SUPERVISOR/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 /> E11 06 06 Report#7201 Page 2 November 04,2004 <br />