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f <br /> ' E <br /> LAME <br /> j <br /> Water ° <br /> Public Water Service Provider Annex-Formation Distance to Public <br /> Proposed L1 Requlrad Water(Feet) <br /> Existing D <br /> NIA <br /> t <br /> Privete WaterD Existing Well D New Well D Well Replacement D <br /> Sewage Disposal <br /> Public Sewage Servlca Provider Annex-Formation Distance to Public j <br /> Disposal Required Sewer Facility <br /> Proposed D <br /> Exhting D <br /> N/A <br /> On-sile Sewage Existing Septic System D New Septic System D Other D <br /> Dis osa!O <br /> Storm Drainage <br /> Public Storm Dralnage Service Provider(ll Public) Annex-Formallon Termin at Drainage Defentlon-Retention <br /> Proposed 17 Required to: Ponds t <br /> 1 <br /> Existing D �. <br /> N/A <br /> Private Storm Drainage On-site Retention Pond(s) D Natural Drainag&Wo Change D Other O <br /> D <br /> Electricitv Natural Gas <br /> Service Provider Distance to Service Service Provider Distance to Service <br /> N/A N/A <br /> School Service Fire Protection Service <br /> Service Provider Distance to Be Service Provider Distance to Fire Station <br /> School <br /> N/A N/A <br /> Exisfin Roads <br /> Road/Street Name R.0.W.Width Pavement Width Curb/Gutter Sidewalks <br /> N/A Yes O No D Yes D No D <br /> Yes D No D Yes D No D <br /> k <br /> Proposed Roads <br /> Sidewalks <br /> Road/Street Name R.O.W.Width Pavement Width Curb/Gutter f <br /> N/A Yes D No D Yes D No O <br /> Yes D No D Yes D No D <br /> I <br /> I <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> 1,the Owner/Agent agree,to defend,Indemnify,and hold harmless the County and its agents,officers and employees from any <br /> claim,action or proceeding against the Owner/Agent's project. <br /> 1,further, certify underpenalty of perjury that I am(check one): <br /> V"Legal property owner(owner includes partner,trustee,trustor,or corporate officer)of the property(s) <br /> Involved In this application,or <br /> ❑ Legal agent(attach proof of file owner's consent to the application of the property's involved in this <br /> application and have been authorized to Nle on their behalo <br /> i <br /> and that the foregoing application statements are true and correct. <br /> � L7(11 <br /> Print Name: Signature: Date:`>• 7 <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> i <br /> F.Vofounlain HouseVdH Application FormslMH-LA-ME Form-MASTER <br /> -6- <br />