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LANE <br /> Public Water Service Provider <br /> Proposed L7 Annex-Formation Distance to Public <br /> Existing C Required Water(Feet) <br /> Irrigation water via BBID canal—no change proposed <br /> as part of this Lot Lino ADustment <br /> Private Water 0 Exist well L7 New Well L7 <br /> ;N; Weil eplacement C <br /> �mw� AW <br /> 0 <br /> 15 <br /> osli_ <br /> Public Sewage Service Provider Annex-Formation Distance to Public <br /> Proposed <br /> DisposalC None existing,none proposed as part of this Lot Line Required Sewer Facility <br /> Existing L7 Adjustment <br /> On-site Sewage Existing Septic System L7 New Septic System 0 Other 0 <br /> Disposal L7 <br /> Public Storm Drainage Service Provider(it Public) <br /> Proposed❑ Annex-Formation Terminal Drainage Detention-Retention <br /> Existing❑ Required to., Ponds <br /> Private Storm Drainage <br /> — C On-site Retention Pond(s) 0 Natural DralnagelNo Change27 Other L7 <br /> Il'l 21 &"!"N�g <br /> N <br /> Service Provider Distance to Service Service Provider Distance fo Service <br /> Modesto Irrigation Ut—sbict 5000'more or less <br /> Vm tI' �AgROMP "U"A"'11 <br /> Service Provider Distance to Elem Service Provider Distance to Fire Station <br /> I School <br /> I-ammersville Elementary School District 4700,more or less Tracy Rural County Fire Protection:Dist 17,000'more or less <br /> Tracy Unified School District <br /> bx sting f <br /> Road/Street Name R.O.W.Width Pavement Width Curb/Gutter Sidewalks <br /> None(accessed by�easement from Grant Yes C No 0 Yes LY No C <br /> Line Road) <br /> Yes L7 No Ld Yes i-f No Li <br /> Sidewalks <br /> Road/Street Name R.O.W.Width Pavement Width Curb/Gutter <br /> None proposed as part of this Lot Line Yes 0 No L7 Yes C No <br /> ❑ <br /> Adjustment <br /> Yes C No 0 Yes C No C <br /> N <br /> � <br /> M21 <br /> 4 ON, <br /> 0, <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 I am(check one): <br /> El Legal property owner(owner includes partner,trustee,trustor,or corporate officer)of the property(s) <br /> involved in this application,or <br /> 0 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 rile on their behalo <br /> and.that,ttreiforegoing-appilcat!6n'staternents-&-re,"e-andcarrect. <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date; <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date. <br /> F:Mountain HouseWH Application ForynsUWH-LA-ME Form-MASTER <br /> P:Xl 9232koffice\Submittals\Ma.tthews-Tuso-LLA-App-Submifted-08-1 63-05.doc <br /> ..3- <br />