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poulN A `1r <br /> ° APPLICATION - DEVIATION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> �d• , , , ,° I FILE NUMBER: DV- <br /> tlddAt' <br /> SITE IMPROVEMENTS AND SERVICES <br /> Water <br /> Annex-Formation Distance to Public <br /> Public Water Service Provider Required Water Feet <br /> Proposed ❑ <br /> Existing ❑ <br /> Private Water❑ Exislinq Well ❑ New Well ❑ Well Replacement ❑ <br /> Sewage Disposal <br /> Public Sewage Annex-Formation Distance to Public <br /> Disposal Service Provider Required Sewer Facility <br /> Proposed ❑ <br /> Existin ❑ <br /> On-site Sewage <br /> Disposal ❑ Existing Septic System ❑ New Septic System ❑ Other ❑ <br /> Storm Drainage <br /> Public Storm <br /> Drainage Service Provider(if Public) Annex-Formation Terminal Drainage Detention-Retention <br /> Proposed ❑ Required to: Ponds <br /> Existing ❑ <br /> Private Storm <br /> Drainage ❑ On-site Retention Pond(s) ❑ Natural Drainage/No Change ❑ Other ❑ <br /> Electricity Telephone Service <br /> Distance to <br /> Service Provider Service Service Provider Distance to Service <br /> School Service Fire Protection Service <br /> Service Provider Distance to Elem Service Provider Distance to Fire Station <br /> School <br /> Existing Roads <br /> Road/Street Name R.O.W. Width Pavement Width Curb/Gutter Sidewalks <br /> Yes❑ No ❑ Yes ❑ No ❑ <br /> Yes E) No ElYes ElNo M <br /> F kDEVSVMPlanning Application Forms0evialion.doc.(Revised 1-6-03) Page 3 of 6 <br />