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LAME AUTHORIZATION SIGNATURES ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. 1, the Owner/Agent agree, to defend, Indemnify, and hold harmless the County and its agents, officers and employees from any claim, action or proceeding against the Owner/Agent's project. 1, further, certify underpenalty of perjury that I am (check one): V"Legal property owner (owner includes partner, trustee, trustor, or corporate officer) of the property(s) Involved In this application, or ❑ Legal agent (attach proof of file owner's consent to the application of the property's involved in this application and have been authorized to rile on their behalo and that the foregoing application statements are true and correct. /�, Print Name: �f 1" �1 `,J Sa %,,- -1 Signature: Date: `>•((7I kt�_ Print Name: Signature: Date: Print Name: Signature: Date: Print Name: Signature: Date: Print Name: Signature: Date: F. Mountain HouseVdH Application FormslMH-(A-ME Form -MASTER Water Public Water Proposed L1 Existing D Service Provider Annex -Formation Required Distance to Public Water (Feet) N/A Privets WaterD Existing Well D New Well D Well Replacement D Sewage Disposal Public Sewage Disposal Proposed D Exlsting D Servlca Provider Annex -Formation Required Distance to Public Sewer Facility N/A On-site Sewage D!s osa! O Existing Septic System O New Septic System D Other O Storm Drainage Public Storm Drainage Proposed O Existing D Service Provider (ll Public) Annex-Formallon Termin at Drainage Required to: Defentlon-Retention Ponds N/A Private Storm Drainage D On-site Retention Pond(s) D Natural Drainag&Wo Change D Other O Electricitv Natural Gas Service Provider Distance fo Service Service Provider Distance to Service N/A N/A School Service Fire Protection Service Service Provider Distance to Elom Service Provider School Distance to Fire Station N/A N/A Exislinj t Roads Road/Street Name R. 0. W. Width Pavement Width Curb/G.Her Sidewalks N/A Yes O No D Yes D No D Yes D No D Yes D No O Proposed Roads Road/Street Name R.O.W. Width Pavement Width Curb/Gutter Sidewalks N/A Yes D No D Yes D No D Yes D No D Yes D No D AUTHORIZATION SIGNATURES ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. 1, the Owner/Agent agree, to defend, Indemnify, and hold harmless the County and its agents, officers and employees from any claim, action or proceeding against the Owner/Agent's project. 1, further, certify underpenalty of perjury that I am (check one): V"Legal property owner (owner includes partner, trustee, trustor, or corporate officer) of the property(s) Involved In this application, or ❑ Legal agent (attach proof of file owner's consent to the application of the property's involved in this application and have been authorized to rile on their behalo and that the foregoing application statements are true and correct. /�, Print Name: �f 1" �1 `,J Sa %,,- -1 Signature: Date: `>•((7I kt�_ Print Name: Signature: Date: Print Name: Signature: Date: Print Name: Signature: Date: Print Name: Signature: Date: F. Mountain HouseVdH Application FormslMH-(A-ME Form -MASTER