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LAME <br /> Water <br /> Public Water Sartre Provider Annex-Formationq1.c..w <br /> ublic <br /> Pmposad 0 <br /> anoinga RequiredV <br /> MHCSD No <br /> Private Water 0 &/ad Well 0 New WWI C WPublic Sewage ServiceProvider AnnexFormagonublicDisposalPropmedDRequired ity <br /> Exlsting O <br /> MHCSD No 0 <br /> O.he Sewage Existing Sepdc System 0 New SBPff System 0 Other D <br /> Dis esaID <br /> Storm Draina e <br /> Public Storm Drainage Sarvlca Pmvidkal0fPubflc) Annex-Formation Terminal Drainage Debmkm*ugrgon <br /> P.Pbsed a Required m. Ponds <br /> Exis Iraq C <br /> MHCSD No Old River N/A <br /> Private Storm Drainage On-site Ratendon Pond(s) 0 Natural Dminageflo Change 0 Other O <br /> O <br /> gElooWdW Naturel Gas <br /> SDistance to Service Service PmNdr M... oto Service <br /> Me0 ATT <br /> Fire Protection Service <br /> SeDistance to Elem Senn.Provide, Distance to Fire Station <br /> School <br /> LUSD <1000' MHCSD <¢p00• <br /> Erlstln Robes <br /> RaadAYreet Name R.O.W.W/mh Pavement WldM CurWGuger Sidewalks <br /> mckiund Cressing Way B8' 40' Yes C® Na 0 Yes 0® No 0 <br /> 106' 48' <br /> Mountaln House Pankwa <br /> Mustang Way 110' 46' Yes O® No D Yes D® No 0 <br /> De Ants Blvd. 110'-118' 46' <br /> Proposed Roads <br /> Sidewalks <br /> RoatlSgaet Name R.O.W.With Pavement width Curb/Guder <br /> Y.0 No D Yes 0 No O <br /> MSO NOO Y..0 NOC <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILEAN APPLICATION. <br /> /,the Owner/Agent agree,to defend,Indemnify,and holdharmless the County and its agents,officers and employees from any <br /> claim,action orproceeding against the Owner/Agent's prolett. <br /> 1,further, comfy underpenalty ofper)ury that I am(check one): <br /> X Legal property owner(owner includes partner,tastes,trustor,or corporate oBlrer)ofthe property(e) <br /> involved in this application,or <br /> ❑ Legal agent(attach proof of the owner's consent M the application of the property's involved in this <br /> application and have been authorized to fila on theirbehatio <br /> and that the foregoing application statements are true and correct <br /> Print Name: See attached signature Page Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:IMountain HouselMH Application FmmsWH-LA-ME Form-MASTER <br />