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12 <br />To Be completed and Submitted by // 111? 7 <br />i x t a Sd 'k'F <br />4 Date issued <br />�t c'p,, <br />*r .. <br />ADDRESS UYA.1�'i <br />APPLICANT'S NAME ADDRESS <br />PROPOSED USE/QWiGE <br />In completing the Land Use investigation draw all Public Health factors on the exhibit. <br />water supplies, etc. Where necessary, draw complgte map of <br />(i.e.) Sewage disposal, <br />ocation of housed, wind direction, etc„ on an attached <br />area showing population density, l <br />piece of plain paper. <br />Size of Parcel Requirements sq. ft. <br />Public Water (name) Public Sewerage (name) <br />SUMMARY OR COMMENTS. � <br />1• <br />FSR OFFICE USE ONLY <br />Report to Planning Standard Paragraph Approval Ej Disapproval M Continuance Q <br />rtY.K: <br />- �%r <br />0. YNioauurr <br />WiW iO . <br />NQ <br />AeR <br />P <br />42 <br />d <br />Y <br />i'f <br />r <br />a <br />� X <br />- �%r <br />0. YNioauurr <br />WiW iO . <br />NQ <br />AeR <br />P <br />42 <br />i'f <br />� X <br />f yt� <br />� y �� <br />9'C a s 4h�y C <br />*� t <br />