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LAIME <br /> i <br /> Water <br /> Fame Water iervka PmNdar ArmeX-.V. ONfamre tp Pdbev <br /> PmPowdD Required Wafer ft u. <br /> Ekt.NngX <br /> Mountain House Community Services District None I On-Site <br /> Private WalerD Erisfln Welt D New Well D Wea Re laument0 <br /> Sewn ,Ols osai <br /> Public Seweaa Service Provldor Aeo.F. neuoa Dieea..m Public 8 <br /> Cup.) Aequhed S.aarlavnay - S <br /> Pmpmed0 <br /> ElsnngX <br /> Mountain House Community Services District None On-site <br /> Oeu/fasawaga Exhaft Septic Sysm D Newseltdc System D other <br /> ma mW0 <br /> 9 <br /> Storm Ordina e <br /> PuhllcSWMDminane Swicv PmWder/frPWlio A. omwfcu T.Minel DraineOe DMenner'Nfeetc. <br /> PrapoecdD _ 'Raqulouf ro: pad, <br /> Eakau,D <br /> a�a <br /> Mountain Home Community None Public atom None 7 <br /> Services Dlstridf Drain System <br /> PM,4sfoaa ondnage On-.he.Refemlon Pond(.)D Natural DminogdNeLh..,.0 DDier0 <br /> D <br /> Elecinci Natural Gas <br /> SaMce PmNdv Dkfence tv servfu SeMuPmvider DlAanceYo Svrvke <br /> e <br /> Modesto irn .Non District Onsite P08S Onsite <br /> f <br /> -School se"k. Fire Pmtecdon Servfce <br /> i <br /> ServkaPmvltivr Distance fe Ekm Serviu Pmv)dar 'DLfencvM Fire Stanw.- <br /> schoof 4t <br /> Lammersvdle Unified School District 100' Tracy Fire 2,000' <br /> Fxtsfln Roads <br /> Road3freet Name RO.W.Wilda Pavement Wldfh Carb/Guder Sidewalks C <br /> Yss X Rea Yes X Ao D <br /> Central Avenue 130' 70' <br /> Tivoli Lane(Private) 30'PRE 22, YmX NoQ 3'ea.D NOX <br /> Cortone Court. 62' 34. Y.X NdD Y.X MCI <br /> Yes O Na D Ye..O Na D <br /> Pmposed Roads <br /> sidewalk. <br /> Readsmost Name ROM Mom Pavement Width Cardeener <br /> Yea D No a Y.0 N.0 <br /> Yd D Mob Yw D No O <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PFOPERTYOR ANAUTHORQEO AGENTMAYRLEAN APPL4CA710N+. <br /> L in.OwneAAgent agree,to d.Amd,indemrelly,andhold harmless the County audits agents,omcersandemployeesJ an any ddd� <br /> .claim,action orpmomding against me OwnenAgmf's pmjecL p <br /> 6 further, certify ued-rp-wty oEperjarythat/am(-/rock-p-), Sip <br /> ❑ Legalpmperfyowner/ownerincludes partnar,'trusfee,Imstar,or corporate officer)of the pmpedy(si <br /> Involvedin this application,or <br /> ❑ Legal agent(attach proof of fhe owner's consent to the application ofthe pnopeny's Inmlvad In this <br /> applies Uanandhave bem auNorhedto Ne on theirbe))alo <br /> andthat the Iomgoing applliagon statemenfsare true and correct, - ( <br /> Pent Name: David Sargent Signature: Date:9/4/18 <br /> Print Name: Signature: Date: <br /> A <br /> Print Name: Signature: Date: <br /> i <br /> Print Name: . Signatums: Date:: <br /> Print Name: Signature, Date: <br /> -3- <br />