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�• LAIMi E : <br /> - Water <br /> Public Water service Provider Annex-Formation Distance to Public <br /> Required Water(Feet) <br /> Proposed❑ 1 <br /> Existing❑ <br /> i <br /> X <br /> Exisfln Well New Well Ly Well Re lacement ❑ <br /> Private Water <br /> Sewa e.Dls osal <br /> Public Sewage Service Provider Annex-Formation Distance to Public <br /> Required Sewer Facility <br /> Disposal i <br /> Proposed❑ <br /> Existing O <br /> On-site sewer$ Existing Septic System New Septic System ❑ Other ❑ <br /> Dis Deaf dT� <br /> Storm-Drains e. <br /> Public Storm Drainage Service Provider of Public) Annex-Formation Terminal Drainage Detention-Retention <br /> Proposed❑ Required to: Ponds <br /> Existing❑ <br /> PrivateStorm,Drainage On-site Retention Pond(s) ❑ Natural Drainage/No Changed Other ❑ <br /> rm <br /> K ' <br /> We'-r7f Gas <br /> Service Provider Distance to Service Service Provider Distance to Service <br /> PG&E PROPANE �} <br /> School'Service Flre'Protection Service <br /> Service Provider Distance to Elem Service Provider Distance to Fire Station <br /> School <br /> LAMMERSVILLE SCHOOL DIST 3 MILES TRACY FIRE 3' MILES <br /> uiiStlri .Roads`' , <br /> Road/Street Name R.O.W Width Pavement Width Curb/Gutter Sidewalks <br /> KELSO ROAD 30' EASEMENT 10 Yes❑ No NX Yes❑ No R( <br /> Yes D No❑ Yes O No❑ <br /> ProposedRoads <br /> Sidewalks <br /> Road/Street Name R.O.W.Width Pavement Width Curb/Gutter <br /> Yes O No V Yes V No O <br /> N/A <br /> Yes O No❑ Yes O No❑ <br /> '0077 <br /> -r t . <br /> AUTHORlZA;TlON{15IONAT..URES <br /> "OIYLY•TYiE OWNER?OF!'M PROPERTY OR'AN A`UTNOftlZED AGENT MAY FlLE AN'AAPI.lCATION <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 /> . � .C]�Legaf.properiyowner(owner_fnciodes_pariner,_trustee,-frusto_r,acnrporate officer o�fthe 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 rile on their behalf) <br /> and that the foregoing application statements are true and correct. <br /> Print me: fizSignature Date: <br /> Print Name: r �r" �) i+�="��r .;�� Signature: Date: ��1�� <br /> Print Name: <br /> ®C.++d � � ;^,1 B+JS�S ghaluree:c. Date: <br /> Print Name: a`,/: _ 1- �_�!L� Signature: Date: <br /> Print Name: Signature: Date: <br /> r <br /> F.Mountain HouselMHApplication FormslMH-LA-MIr Form-MASTER <br /> r <br />