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LAIME <br /> Water <br /> Public Water Service Provider Annex-Formation Distance to Public <br /> Proposed O Required Water(Feet) <br /> Existing X <br /> Mountain House Community Services District None On-Site <br /> Private Water D Existinq Well o New Well o Well Replacement D <br /> Sewa a Dis osal <br /> Public Sewage Service Provider Annex-Formation Distance to Public <br /> Disposal Required Sewer Facility <br /> Proposed D <br /> Existing X <br /> Mountain House Community Services District None On-Site <br /> On-site Sewage Existing Septic System D New Septic System D Other D <br /> Disposal D <br /> Storm Drainage <br /> Public Storm Drainage Service Provider(if Public) Annex-Formation Terminal Drainage Detention-Retention <br /> Proposed D Required to: Ponds <br /> Existing D <br /> Mountain House Community None Public Storm None <br /> Services District I Drain System <br /> Private Storm Drainage On-site Retention Pond(s) D Natural Drainage/No Change D Other D <br /> D <br /> Electricity Natural Gas <br /> Service Provider Distance to Service Service Provider Distance to Service <br /> Modesto Irrigation District On-Site PG&E On-Site <br /> School Service Fire Protection Service <br /> Service Provider Distance to Elem Service Provider Distance to Fire Station <br /> School <br /> Lammersville Unified School District 2,000' Tracy Fire 2,000' <br /> Existing Roads <br /> Road/Street Name R.O.W.Width Pavement Width Curb/Gutter Sidewalks <br /> Yes X No D Yes X No D <br /> Walcott Avenue 62' 41' <br /> Yes X No D Yes D No X <br /> Langord Drive (Private) 30'PRE 22' <br /> Yes X No D Yes X No D <br /> Huntington Avenue 54' 38' <br /> Yes X No D Yes D No X <br /> Unnamed Road (Private) 30'PRE 22' <br /> Proposed Roads <br /> Sidewalks <br /> Road/Street Name R.O.W.Width Pavement Width Curb/Gutter <br /> Yes D No D Yes D No D <br /> Yes D No D Yes D No D <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> I, the Owner/Agent agree, to defend,indemnify, and hold harmless the County and its agents, officers and employees from any <br /> claim, action or proceeding against the Owner/Agent's project. <br /> 1, further, certify under penalty of perjury that I am(check one): <br /> )$�Legal property owner(owner includes partner, trustee, trustor, or corporate officer)of the property(s) <br /> involved in this application, or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this <br /> application and have been authorized to file on their behalf) <br /> and that the foregoing application statements are true and correct. <br /> 1-7 <br /> Print Name: Lc'� Signature: Date: 7Iti,>i y <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> -3- <br />