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LAME <br /> Water <br /> F <br /> Public Water Service Provider Annex-Formation Distance to Public <br /> Proposed O Required Water(Feet) <br /> Exisling X <br /> Mountain House Community Services District None On-Site <br /> Private Water O istinq Well O New Well D Well Replacement O <br /> Sewage Disposal <br /> Public Sewage Service Provider Annex-Formation Distance to Public <br /> Disposal Required Sewer Facility <br /> Proposed O <br /> Existing X <br /> Mountain House Community Services District None On-Site <br /> On-site Sewage Existing Septic System O New Septic System O Other D <br /> Disposal D <br /> Storm Drainage <br /> Public Storm Drainage Service Provider(if Public) Annex-Formation Terminal Drainage Detention-Retention <br /> Proposed D Required to: Ponds <br /> Existing D <br /> Mountain House Community None Public Storm None <br /> Services District Drain System <br /> Private Storm Drainage On-site Retention Pond(s) D Natural Drainage/No Change o Other O <br /> O <br /> Electricity Natural Gas <br /> Service Provider Distance to Service Service Provider Distance to Service <br /> Modesto Irrigation District On-Site PG&E On-Site <br /> School Service Fire Protection Service <br /> Service Provider Distance to Elem Service Provider Distance to Fire Station <br /> School <br /> Lammersville Unified School District 0' Tracy Fire 3,400' <br /> Existing Roads <br /> Road/Street Name R.O.W. Width Pavement Width Curb/Gutter Sidewalks <br /> Yes X No D Yes X No O <br /> Durrant Terrace 65' 40' <br /> Yes X No D Yes D No X <br /> Vecindad Street 65' 40' <br /> Yes X No D Yes X No D <br /> Bancroft Way 65' 40' <br /> Yes O No D Yes O No D <br /> Proposed Roads <br /> Sidewalks <br /> Road/Street Name R.O.W.Width Pavement Width Curb/Gutter <br /> Yes D No D Yes D No D <br /> Yes D No D Yes D No D <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <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 /> ❑ Legal property owner(owner includes partner, trustee, trustor, or corporate officer)of the property(s) <br /> involved in this application, or <br /> U/ 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: ID,,V Signature: Date: 711f/rq <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br />