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r.•"T) 11C- <br /> Ar 1' � �- /rn5 <br /> • y <br /> To Be completed and Submitted by <br /> Date Is/sued <br /> ADDRESS UPA <br /> APPLICANT'S NAME ADDRESS <br /> PROPOSED USE/CHANCE <br /> In completing the Lard Use investigation draw all Public Health factors on the exhibit. <br /> (i.e.) Sewage disposal, water supplies, etc. Where necessary; draw complete "map of <br /> area showing population density, location of housed, wind direction, etc„ on an attached <br /> piece of plain paper. <br /> Size of Parcel Requirements sq. ft. <br /> public Water (name) Public Sewerage (name) <br /> SUM4ARY OR ooMMENTS: <br /> 1. - <br /> 2. <br /> 3. <br /> 4. <br /> On basis of above, I recommend: Approval Denial -7— Continuance <br /> Signed <br /> FOR OFFICE USE ONLY <br /> Report to Planning Standard Paragraph Approval Disapproval Continuance Q <br /> Y <br /> a <br /> tH o6 06 3/71 <br />