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fCa<I .1t1.�r <br /> Parcel Number Existing or Proposed Use of Parcel Square Footage <br /> or Acreage <br /> ci b I <br /> SITE IMPROVEMENTS AND SERVICeS <br /> Service Provider Annex-Formation Distance to Public <br /> Public Water❑ Required Water(Feet) <br /> Private Water Existing Well ❑ New Well Well Replacement ❑ <br /> .. ........... <br /> Public Sewage Service Provider Annex-Formation Distance to Public <br /> Disposal ❑ Required Sewer Facility <br /> On-site Sewaa Existing Septic System ❑ New Septic System Other ❑ <br /> Disposal <br /> Public Storm Service Provider Annex-Formation Terminal Drainage Detention- <br /> Drainage O Required to: Retention Ponds <br /> Private Storm <br /> // On-site Retention Pond(s) ❑ Natural Drainage/No Change Other ❑ <br /> rlraineAe <br /> ElectrlCitY ttlkltflt LAIR' <br /> Service Provider Distance to Service Service Provider Distance to <br /> Service <br /> 71, <br /> TelgRho�1�94rvjC4 Cable Television Service <br /> _. .. <br /> Service Provider Distance to Service Service Provider Distance to <br /> Service <br /> School S4rvicift Elft!proteoWn Service <br /> Service Provider Distance to Elem Service Provider Distance to Fire <br /> School Station <br /> LC <br /> Road/Street Name R.O.W.Width Pavement Width Curb/Gutter Sidewalks <br /> s c' 1 Yes❑ No Yes❑ No <br /> AO <br /> 0' Yes O No Lk� Yes❑ No K <br /> �w <br /> Hoed/Street Name R.O.W.Width Pavement Width Curb/Gutter Sidewalks <br /> Yes❑ No O Yes❑ No❑ <br /> Yes 0 No 0 Yes 0 No❑ <br />