Laserfiche WebLink
LAME <br /> Water <br /> Public Wefer Service Provider Annoa-Formation Dlsience lc Public <br /> PropusedD Requtretl Waf.r(Feeg <br /> wale ga <br /> NIA <br /> PrNafe fYatwa Edsfin Well D Naw Well O Well R¢ lacemenl D <br /> Sawa eDisposal <br /> Public Seize S.rvke Provider Annev-Formallon Distance to Public <br /> Dlspusai Requhad Sewer Fmllify <br /> ProposedD <br /> EdslingD <br /> N/A <br /> on-sn.Sewage Exodng Sepik System D Newsepfla Syatam D Other <br /> D/s osa/0 <br /> Storm Dm e <br /> PublicSlarm Drainage Service Providwgl Public) Armex-Formmlon Terminal DralnegeDefwtlea.Retengon <br /> Prc,..dO Required b: Ponds <br /> ExlsnngD <br /> NIA <br /> Private Sib.Drainage th elte Retennon Pond(s)O Naf ver Oralragelle Chanes O mbar D <br /> O <br /> EleeVielfV Natural Gas <br /> Service PMOder Distance to Sarvke Service ProvMw Distance to Sell.. <br /> NIA NIA <br /> School Service Fire Protection Service <br /> Sarvke Prowder Distance f,El.. S.M..Pmvldw Dialenceto Flm Shffon <br /> School <br /> N/A NIA <br /> EzratlD Roads <br /> Raad/Sfrew Nam. R.O.W.MM Pavement WMfh CorDlhatir Sidewalks <br /> Yea O no D Yes O No O <br /> Yea O M.0 Yes O Me I <br /> Proposed Roads <br /> Sitlewaiks <br /> RaadrSfreal Name R.O.W.Main Pavamenf Width Cmf✓Ganer <br /> Great Valla,Parkway Varies(119'-125) 54' r N MU Yea IX N.0 <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 OwnerlAgent agree,to defend,Indemnify,and hold harmless the County and its agents,officers and employees from any <br /> claim,action orproceeding against the OwnerlAgenrs project <br /> I,further, certify underpanalb o(perjury that]am(check one): <br /> ❑ Legal property owner(ownerincludes partner,tastes,"star,or corporate officer)ofthe proparry(s) <br /> Involved In Oils application,or <br /> d�Legafagent(attach proof of fhe owner's consent to the application of the properVs involvedlin this <br /> application and have been authorized to His on their behaln <br /> and that the foregoing applicationstatementsare true and correct. p <br /> Print Name: I gLV'j&k ✓n(gCK� Signature:: Data:�I(Sl t <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F.'NAounlam HouselMHAppliceion FomiswlH-LA-ME Form-MASTER <br /> -6- <br />