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<br /> ` Public Water Service Provider: Annexation or Formation Distance to Public Water(ft.)
<br /> G Required? r
<br /> Existing �I
<br /> Proposed
<br /> ❑ Yes No ❑
<br /> Private Water:
<br /> Existing Well ❑ New Well ❑ Other:
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<br /> Public Sewage Disposal Service Provider: Annexation or Formation Distance to Public Sewer
<br /> Required? Facility(miles)
<br /> Existing ❑ 7
<br /> Proposed ❑ Yes E] No❑
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<br /> Required? Retention Ponds?
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<br /> Drainage: On-site Ret itidci Ponds) ❑ '
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<br /> Service Provider: Distance to Service: Service Provider:
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<br /> Dist..to Fire Station
<br /> District OD (/N! Distance to School /Service Provider n
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<br /> Road/StrcetName R-O•W'Width
<br /> Pavement Width Curb/Gutter Sidewalks
<br /> Yes�5No❑ Yes❑ No
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