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LAME <br />Water <br />Public Wafer <br />Proposed <br />Exlsfing 0 <br />Service ProviderAnnenFormaflon <br />Required <br />Distance to Public <br />Water (Pont <br />Mountain House C...Yf!1A Services District <br />Yes <br />Private WaterO <br />Exisgn Well 0 New Well O Well Re lacement O <br />Sewa a Disposal <br />Public Sewage <br />Disposal <br />Proposed0 <br />Etlsflog 0 <br />Service Provider <br />Annex -Formation <br />Required <br />Distance to Public <br />Sewer Facility <br />Mountain House Community Services District <br />yes <br />On-sife Sewage <br />Disposal 0 <br />Edoung Septic System 0 New Septic System 0 Other 0 <br />Storm Dmina e <br />Public Storm Drainage <br />Proposetl0 <br />Exls Inti O <br />Service Provider(If Public) <br />Annex -Formation <br />Required <br />Terminal Drainage <br />to: <br />Defengon-Refentlon <br />Ponds <br />Mountain House Community Services <br />District <br />e5 <br />e a <br />Private Storm Drainage <br />O <br />On-slte Retention Ponds) O NafvaIDreinagaJNO Change D Ofher0 <br />Electricity <br />Natural Gas <br />Service Provider D/stance fe Service <br />Service Provider Distance W Service <br />O esiO irrigarion uisrrlcr un sire <br />pudk un site <br />School Service <br />Fire Protection Service <br />Service Provider <br />Distance to Elam <br />School <br />Service Provider <br />Distance to Fire Station <br />Tracv Fire <br />Exisfina Roads <br />Roedit'E'd Name R.O.W. Width <br />Pavement Width <br />Cur r <br />Sld ks <br />Grant Line Oa <br />23 <br />Yes 0 No <br />Yes 0 No <br />Yes O No 0 <br />Yes 0 No 0 <br />ProposedRoads <br />Road/SfreW Name <br />R.O.W. WIft <br />Pavement Width <br />curh/Mmw <br />Sidewalks <br />Grant Line Road - Improved <br />140' <br />60' <br />Yea Na D <br />res No O <br />Yes 0 No 0 <br />Yes 0 No 0 <br />AUTHORIZATION SIGNATURES <br />ONLYTHEOWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br />I, 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 />i,further, certify underpenaity ofperjury thatl am (check one): <br />6 Legal property owner (owner Includes partner,trustee, frustar, or corporate officer) of the propeny(s) <br />Involved in this application, or <br />❑ Legal agent(etlach proof ofthe owner's consent to the application offhe property's Involved In this <br />application and have been authorized to the on their behalf) <br />and that the foregoing application statements are true and correct. <br />Print Name: ✓. Signature: Date: Ipr13 jI <br />Print Name: Signature: Date: <br />Print Name: Signature: Date: <br />Print Name: Signature: Date: <br />Print Name: Signature: Date: <br />F.Wountain HonSa1MH Application Folms%MH-LA-ME Form -MASTER <br />-5- <br />