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LA/ME <br /> Water <br /> Public Water Service Provider <br /> Proposed® Anner-formation Distance to Public <br /> Existing Required Water(Feet) <br /> MHCSD <br /> 0 <br /> Private Watery Existing Well D New Well O <br /> Well Re lacement p <br /> Sewa a Dls osal <br /> Public Sewage Service Provider <br /> Disposal Anner-Formation Distance to Public <br /> Proposed® Required Sewer Facility <br /> Existing p <br /> MHCSD 0 <br /> On-site Sewage Existing Septic System O New Septic System p Other O <br /> Dis osal p <br /> .Storm Drainage <br /> Public Storm Drainage Service Provider(if Public) Annex-Formation Terminal Drainage Detention-Retention <br /> Proposed W Required <br /> Existing p q t° Ponds <br /> MHCSD <br /> Old River <br /> Private Storm Drainage On-site Retention Pond(s) p Natural Drainage/No Change p Other p <br /> O <br /> Electdcit Natural Gas <br /> Service Provider Distance to Service Service Provider Distance to Service <br /> MID 0 PG&E I0 <br /> School.Sery/ce. Fire Protection Service <br /> Service Provider Distance to E/em Service Provider Distance to Fire Station <br /> School <br /> !_ammersville Unified Tracy Fire <br /> Existin Roads <br /> Road/Street Name R.O.W.Width Pavement Width Curb/Gutter Sidewalks <br /> Mountain House Parkway 60 40 Yes p Al.® Yes p No <br /> Yes p No O Yes p No p <br /> Proposed Roads <br /> Road/Street Name R.O.W.Width Pavement Width Curb/Gutter Sidewalks <br /> NIA Yes a No p Yes O No O <br /> Yes O No O Yes O No O <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> 1, 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 1 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 /> R' 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 /> Print Name: DAV I ��V'oley�l— Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: II <br /> J <br /> PlMountain House1MH Application FormsIMH-LA-ME Form-MASTER <br />