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LH/IV!t � <br /> Water <br /> Public Waters Service Provider Annex-Formation Distance to Public <br /> Proposed � Required Water(Feet) <br /> Existing d <br /> Mountain House Community ServicesDistrict Yes <br /> Private Water O Existing Well O New Well O Well Replacement O <br /> Sewage Disposal <br /> Public Sewage Service Provider Annex-Formation Distance to Public <br /> Disposa. Required Sewer Facility <br /> Proposed <br /> Existing d <br /> Mountain House Community Services District Yes <br /> On-site Sewage Existing Septic System O New Septic System O Other O <br /> Dis osal0 <br /> Storm Drainage <br /> Public Storm Dai ge Service Provider(if Public) Annex-Formation Terminal Drainage Detention-Retention <br /> Proposed7, Required to: Ponds <br /> Existing O <br /> ountain House Community <br /> Services District Yes <br /> Private Storm Drainage On-site Retention Pond(s) O Natural Drainage/No Change L7 Other O <br /> 0 <br /> Electricity Natural:Gas <br /> Service Provider Distance to Service Service Provider Distance to Service <br /> o esto Irrigation District <br /> School Service Fire Protection Service <br /> Service Provider Distance to Elem Service Provider Distance to Fire Station <br /> School <br /> Tracy Fire <br /> Existing Roads <br /> Road/Street Name R.O.W.Width Pavement Width CurblGutter Sidewalks <br /> NIA Yes O No O Yes O No a <br /> Yes O No O Yes O No O <br /> Proposed Roads <br /> Sidewalks <br /> RoadlStreet Name R.O.W.Width Pavement Width CurblGutter <br /> Central Parkway 130'-142' 54' Yes No O Yes_1 No O <br /> Yes O No O Yes O No a <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 under penalty of perjury that I am(check one): <br /> ❑ 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 the owner's consent to the application of the property's involved in this <br /> application and have been authorized to file on their behalo <br /> and that the foregoing application statements are true and correct. <br /> Print Name: A&'V �� _ Signature: Date:7II51il <br /> Print Name: Gtc�sa-t 1Ga-�• LS Signature: Date- �b, 11 <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:IMountain HouselMH Application FormslMH-LA-ME Form-MASTER <br />