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LAIME <br /> Water <br /> Public Water Service Provider Annex-Formation Distance to Public <br /> ProposedC Required Water(Feet) <br /> Existing C <br /> Mountain House CSD No <br /> Private Water L7 Extsfing Well C New Well C Well Replacement C <br /> Sewage Disposal <br /> Public Sewage Service Provider Annex-Formallon Distance to Public <br /> Disposal Required Sewer Facility <br /> Proposed C <br /> Existing C <br /> Mountain House CSD No <br /> On-site Sewage Existing Septic System C New Septic System C Other C <br /> Disposal C <br /> Storm f irainage <br /> Public Storm Drainage Service Provider(Ir Public) Annex-Formation Terminal Drainage Detentlon-Retention <br /> Proposed C Required to: Ponds <br /> Existing C I <br /> Mountain House CSD No <br /> Private Storm Drainage On-slie Retention Pond(s) C Natural Dralnageltio Change COther C <br /> O <br /> Electricity Natural Gas <br /> IIService Provider Distance to Service Service Provlder I Distance to Service II <br /> �Modesto Irrigation D.istriot Pacific Gas and Electric <br /> I School Service Fire Protection Service <br /> Service Provider Distance to Elem Service Provider I Distance to Fire Station <br /> School <br /> II Lammersville Unified 100 feet French Camp Fire 11/4 mile <br /> Exfstlnq Roads <br /> IIRoad/StreetName R.O.W.Width I Pavement Width ( CurblOutter I Sidewalks II <br /> II I Yes C No C I Yes C No C II <br /> I Yes C No C Yes C No C <br /> Proposed Roads <br /> Sidewalks <br /> Road/Street Name R.0.W,Width I Pavement Width I CurblOufter 1 II <br /> II I I Yes O No C I Yes C No C <br /> Yes C No O ( Yes O No O <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE ANAPPLICATION. <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 /> EX 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 behalf) <br /> and that the foregoing application statements are true and correct. <br /> Print Name: David Best,Authorized Agent Signature: - Date:9/28/2 20 <br /> Print Name: DerAld A;H Signature: _ Date.0 <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> RlMountain HouselMH Application FofmsWH-LA-ME Form-MASTER <br /> -6- <br />