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LAME <br /> Water <br /> Public Water Sarvka Promor Anner Farmalien Distance to Public <br /> Propos.dI ir,shad Wakr(Fem) <br /> Existing D <br /> N/A <br /> Pdvale Water Exklln Well O New Well O Woulbe lacemenl O <br /> Sawani.Disposal <br /> Public$..a. Sevice Provider Annex-Farmellan Dlaon-a, <br /> Public <br /> Disposal Required Sewer Fadllty <br /> Proposed D <br /> Erktinga <br /> NIA <br /> 0 .11.Sewage ExlsNngsepllcsyslem D Newsepgc System D other a <br /> Dis sel0 <br /> Slorm Omina e <br /> Public St..Drainage servka Provide QlPubllc) Anner-Formadon T.rminal Dralo.ga Direnll.aR.N.U.n <br /> Propoaed0 RWufmd is: Ponds <br /> Er1s11nB D <br /> NIA <br /> Private Storm Drainage on-ell.Raises.Penn(.)O Natural DraNagaMo change D Other <br /> D <br /> Electrialtv Natural Gas <br /> Servke Provider Distance to Sorvka Service ProviderDlsbnn to Service <br /> N/A NIA <br /> School Service Fre Protection Service <br /> Samoa Provider Distance to Elam Service Provider Distance to FhrStaNen <br /> Scheel <br /> NIA N/A <br /> EXISMIF Roads <br /> Ro..Moral Name R.O.W.Width Pavement width Curto Guaer Slaime-ft <br /> Yea D No O Yes D Na O <br /> YaeD No0 YssD N.O <br /> Proposed Roads <br /> Sitlawaixs <br /> Reawslreat Name RO.WWW(b Pavement Mont CurWGuNer <br /> Great Valley Parkway Varies(I 19'125) ' Yas@NeO Vas� NoO <br /> 54 <br /> Yea No Y.aO NOD <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTYOR AN AUTHORIZED AGENT MAYFILEAN APPLICATION. <br /> 1,the OwnedAgent 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, certhy underpenatty ofparjury that I am(check one): <br /> ❑ Legalproperty owner(owner includes partner,trustee,trustor,orcorporate ofcm)oflheproperly(s) <br /> Involved In this application,or <br /> LV/Legal agent(attach proof of the owner's consent m the oppllcagon of the property's Involved in this <br /> application and have been authorized to file on theirbehalo <br /> and that the foregoing application statements am true and correct, p <br /> Print Name:2N 1P '�jG�r Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F.Wwntain HouseWHApplication Foo WH.LA-MEFmm-)RASTER <br /> -6- <br />