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APPLICATION ouriTY oOM COMMUNITY LINE ADJUSTMENT DEPARTMENTSAN ::::.:::::::::::::::::::::::::::::::::::.:......::::.:::::.:::::::::.;:.;:.:.:.:.:;.:.::;.::.::.::.;............RQ ..C2 D.PARCELS................................. . Parcel Number Existing or Proposed Use of Parcel Existing Proposed Square Footage Square Footage or Acreage or Acreage X45-17I e D2G ah cs 1, 4 . 2 74 SITE.IMPROVEMENTS AND SERVICES ar..:::. Service Provider Annex-Formation Distance to Public Public Water❑ Required Water (Feet) Private Waters Existing Well ® New Well ❑ Well Replacement ❑ r::r:.>:::......... 9. p:::.::: :: :..:... Public Sewage Service Provider Annex-Formation Distance to Public Disposal❑ Required Sewer Facility On-site Sewage Existing Septic System IN New Septic System ❑ Other ❑ Disposal IN a j Public Storm Service Provider Annex-Formation Terminal Drainage Detention- Drainage❑ Required to: Retention Ponds Private Storm On-site Retention Pond(s) ❑ Natural Drainage/No Change 1K Other ❑ Drainage 0 a u I as reetrktt ::»::»>::>::>::>::>::;:::>:>:• . ............ .....: N..t ra G. Service Provider Distance to Service Service Provider Distance to Service bl ele ision'Service' ::::::i.;:`::':::'E ,' :::'::i:EYi`i;::.;::i; O @ CB`: i:`: "2::i;'isE:i2:i: E2:<::'E::�tri?:;: `:'.'''iir'0'?`''''::"::.:.:`Ci;;if..... Ga e T v xrePr,:.rte s :.;;:.:.:. ::.;:; Service Provider Distance to Service Service Provider Distance to Service ortelf X;,.;:.::. .::;:;::.: .;:.::.;;;:.;;:<echo..oE:iservka.;.;:::;:.;:.<:::...:.......;:.;:.;;:.;......;.::::.; Service Provider Distance to Elem Service Provider Distance to Fire School Station OH sc �oo! l S r .......: ::<.>;:. Road/Street Name R.O.W.Width Pavement Width Curb/Gutter Sidewalks IC Yes❑ No MYes❑ No In Yes❑ No❑ Yes❑ No❑ Road/Street Name R.O.W.Width Pavement Width Curb/Gutter Sidewalks Yes ❑ No❑ Yes❑ No❑ Yes 0 No 0 Yes 0 No 0