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I; <br /> Private WalerA Existing Well New Well ❑ Well Replacement Cl <br /> Public Sewage Service Provider Annex-Formation Distance to <br /> Disposal Required Public Sewer <br /> Proposed ❑ <br /> Facility <br /> Existing ❑ <br /> On-cite Sewage Existing Septic System ❑ New Septic System ❑ Other ❑ <br /> Diepocal,E3� <br /> L <br /> Public Storm Service Provider (M Public) Annex-Formatlon Terminal Dralnage Detention- <br /> Drainage Required to: Retention Ponds <br /> Proposed ❑ <br /> Existing ❑ <br /> Private Storm O"he Retention Pond(s) ❑ Natural Dralnage/No Change Other ❑ <br /> Drainage <br /> Electdclty Telephone Service <br /> Service Provider Distance to Service Provider Distance to <br /> Service Service <br /> n <br /> ' <br /> Fhe P>fSchool Service <br /> oteicuon Service <br /> Service Provider Distance to Elem Service Provider Distance to Fire <br /> School Station <br /> £xiSting ROfils <br /> Road/Street Name R.O.W. Width Pavement Width Curb/Gutter Sidewalks <br /> Yes❑ Nofl:� Yes ❑ No') <br /> Yes ❑ No❑ Yes❑ No ❑ <br /> -3. <br />