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APPLICATION - DEVIATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> - .V <br /> Service Provider Annex-Formation Distance to Public <br /> Public Water Required Water (Feet) <br /> Existing ❑ <br /> Proposed ❑ <br /> Private Water❑ Existing Well ❑ New Well ❑ Well Replacement ❑ <br /> .......................................................................................................................... n g I <br /> Public Sewage Service Provider Annex-Formation Distance to Public <br /> Disposal Required Sewer Facility <br /> Existing ❑ <br /> Proposed ❑ <br /> On-site Sewage Existing Septic System �( New Septic System ❑ Other ❑ <br /> Disposal❑ <br /> ....... __._._ <br /> .................................................................................................................................................................................................................................................................... <br /> ................................................................................................................................................................................................................................................................... <br /> .................................................................................................................................................................................................................................................................... <br /> ................................................................................................................................................................................................................................................................... <br /> .................................................................................................................................................................................................................................................................. <br /> : .:.::::;.<;::..: .:..m;:pra nape <br /> Public Storm Service Provider (if Public) Annex-Formation Terminal Drainage Detention- <br /> Drainage Required to: Retention Ponds <br /> Existing are-, <br /> Proposed ❑ 046"D,4 MJ��' A <br /> Private Storm On-site Retention Pond(s) ❑ Natural Drainage/No Change ❑ Other ❑ <br /> Drainage❑ <br /> .......... ......... __..... ...._. ....._.... ......._.. ... ._... ........._.. _._ ....... ...._..._ ............_... .._ ...._.._ <br /> ................................................._..................................................................._. .................................................................._.........,....................._................._... <br /> .................................................................................................................................................................................................................................................................. <br /> .................................................................................................................................................................................................................................................................. <br /> ................................................................................................................................. ................................................................................................................................ <br /> clrt�tty 7elephQrn <br /> Service Provider Distance to Service Service Provider Distance to <br /> Service <br /> p Cc 4 L ��IL l3�LL <br /> ... .................. <br /> ... ............ ............. . ....... .............. ....................... .... ....... ............. ... ........... ....... ..... ................ ...... . ... ........ .......................................... <br /> ................................................................................................................................. ............................................................................................................................... <br /> >::::»::::::>: ::> : shoot:: ecvic >:. F r 'raieclian:ServiCO . <br /> Service Provider Distance to Elem Service Provider Distance to Fire <br /> School Station <br /> ........... .......... _ _ __. __...... ........._ _ ...........__ <br /> ..._................... ..... ...... ... .. __.... __. _ _. <br /> ................................................................................................................................................................................................................................................................. <br /> ................................................................................................................................................................................................................................................................... <br /> >:: Extstin::.Flvads<:?:::;::>:::>::::;: <br /> is <br /> Road/Street Name R.O.W. Width Pavement Width Curb/Gutter Sidewalks <br /> Q Y>N C Nj 0 ,- T Yes ❑ No,5�1 Yes ❑ No X <br /> Yes ❑ No❑ Yes ❑ No❑ <br /> - -3- <br />