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°P4u�N APPLICATION - DEVIATION <br /> :i <br /> < SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> kA ', <br /> \ WW <br /> FILE NUMBER: DV- <br /> �. <br /> 9�4;0R P <br /> SITE IMPROVEMENTS AND SERVICES <br /> Water <br /> Annex-Formation Distance to Public <br /> Public Water Service Provider Required Water Feet <br /> Proposed ❑ <br /> Existin ❑ �/ <br /> Private Water❑ ExistingWell L/ New Well ❑ Well Replacement ❑ <br /> Sewage Disposal <br /> Public Sewage Annex-Formation Distance to Public <br /> Disposal Service Provider Required Sewer Facility <br /> Proposed ❑ <br /> Existing❑ <br /> On-site Sewage <br /> Disposal E] Existing Septic System ❑ New Septic System Other El <br /> Storm Drainage <br /> Public Storm <br /> Drainage Service Provider(if Public) Annex-Formation Terminal Drainage Detention-Retention <br /> Proposed ❑ Required to: Ponds <br /> Existing ❑ <br /> Private Storm <br /> Drainage ❑ On-site Retention Pond(s) ❑ Natural Drainage/No Change L� Other ❑ <br /> Electricity Telephone Service <br /> Distance to <br /> Service Provider Service Service Provider Distance to Service <br /> -FL K—: 6T <br /> School Service Fire Protection Service <br /> Service Provider Distance to Elem <br /> School Service Provider Distance to Fire Station <br /> Existing Roads <br /> Road/Street Name R.O.W.Width Pavement Width Curb/Gutter Sidewalks <br /> CSC' Yes E] No Yes El Nod <br /> Yes❑ No❑ Yes ❑ No❑ <br /> =:\DEVSVC\Planning Application Forms\Deviation.doc.(Revised 5-11-09) Page 3 of 6 <br />