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LAME <br /> =MIHCSD <br /> Public WaterAnnex-FormationAftptac�ent <br /> Propaseb'ORequired <br /> ExlslingC <br /> PrivateWaterO W <br /> Sewa a Dis osal <br /> Public Sewage Service Provider AnaenFormetlon Distance to Public <br /> Disposal Required Sewer Faclll <br /> Proposed a N <br /> Exis ngO <br /> MHCBD No 0 <br /> Onske Sewage editing Septic System 0 New Septic System 0 Other C <br /> Dls sa/0 <br /> Storm Dralna e <br /> Public Storm Drainage Se -PmvFdergfPubllc) Annex-Fotmatlon Termina/Drunt.ge DetmgomRetention <br /> PmposedU Requimd b: Ponds <br /> Exisiln9 0 <br /> MHCSD No Old River N/A <br /> Private Storm Drainage On-site Retention Pond's) O Natural Dralnagehio Change O Other O <br /> 0 <br /> Eltu,tricitv Natural Gas <br /> Service Pmvider Distance M Service Service Provider Distance to S"Ise <br /> Mid 0 ATT p <br /> School Service Fire Protection Service <br /> Service Provider Distance to El. Swica Provider Distance to Fire Station <br /> Schaal I <br /> LUSD <g0(q' MNCSD @000' <br /> Existlnr Reads <br /> RoaNsgeef Name R.O.W.Width Pavement Width Curb/Guger Sltlewalka <br /> Wicktund Crossing Way 88' 40' Yes O® NoOYes C® No <br /> 106' 48' <br /> Mountala House PaMwit <br /> Mustang Way 110' 46' Yes O® No Yes O® No <br /> De Ants Blvtl. 110'-118' 46' <br /> proposed Roads <br /> RoatlStreet Nemo R.O.W.width, vamm <br /> Pat W/dN CurWGuffer Swewalks <br /> Yeac NOC Yesa 1100 <br /> Y"a No0 Yes No0 <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> I,the OwnerlAgent 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 pmiact. <br /> 1,further, certify underpenatty ofper/ury that l am(check one): <br /> X Legal property owner(ownerincludes Partner,trustee,mabr,or corporate officer)ofthe pmperty(s) <br /> Involved in this application,or <br /> ❑ Legal agent(attach proof of the owner's consent to the application ofine property's involved In this <br /> application and have been authorized to file on their behalo <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:Vrfountain HouwV fN Application Fam31MH-LA-ME Pam-MASTER <br />