Laserfiche WebLink
LAME <br />Water <br />Public Wafer <br />Proposed 47 <br />Existing <br />Service Provltler <br />Annex -Formation <br />Required <br />Distance to Public <br />Water (Feet) <br />Mountain House Commun/ Services District <br />Yes <br />Pd,0a WaterD <br />Existl WWell 0 New Well O Well Re lacemem 0 <br />Sewage Disposal <br />Public Sewage <br />D/sposal <br />Pmposetl0 <br />Exla ln9 0 <br />Service Provider <br />Annex -Formation <br />Required <br />Distance to Public <br />Sewer Faclllry <br />Mountain House Community Services District <br />a5 <br />On-sife Sewage <br />Deep,osa10 <br />Existing Septic System 0 New Sepfle System 0 Other 0 <br />Storm Dealrect. <br />Public Sturm Drainage <br />Proposed <br />Existing O <br />Service Provider (if Public) <br />Annex -Formation <br />Required <br />Termina/Dralnage <br />to: <br />Dattedan-Retention <br />Ponds <br />Mountain House Community Services <br />District <br />Yes <br />L)elta <br />Private Storm Drainage <br />D <br />Oms/te Retention Pond(s) 0 <br />Natural Dralntge/NO Change 0 Other 0 <br />E/ecMel - <br />Natural Gas <br />service Provider D/stance to Service <br />Service ProvltlerDistance to Service <br />Modesto alga On /S r C n site <br />n sl a <br />School Service <br />Fire Protection Service <br />Service Provider <br />Distance to Elam <br />School <br />Service Provider <br />Distance to Fire Station <br />Fire <br />---_LTMCV <br />Exisfinq Roads <br />Ro e/Iumet Name R.O.W. Width <br />Pavement W/tl0 curb/a., <br />Sltl ke <br />Cirent Line Road 60 <br />23 Yes 0 Na <br />Yes 0 No <br />YW 0 NOD <br />Yes 0 No 0 <br />Proposed Roads <br />RuaNSheef Name <br />R.O.W. Width <br />Pavement Width <br />Curb/Guaer <br />Sidewalks <br />Grant Line Road - Improved <br />140' <br />60' <br />res Na Cl <br />res No D <br />vaso NOD <br />Yes 0 NOD <br />AUTHORIZATION SIGNATURES <br />ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAYFILE AN APPLICATION. <br />I, the OwneNAgent 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 />I, further, certify underpena/ty ofperjury that/ 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 />❑ Legal agent (anacb proof of the owner's consent to the application of the property's Involved in this <br />application and have been authorized to Me on their behall) <br />and that the foregoing application statements are true and correct. <br />Print Name: - b,Signature: Date: 6/i3�r <br />Print Name: Signature: Date: <br />Print Name: Signature: Date: <br />Print Name: Signature: Date: <br />Print Name: Signature: Date: <br />F:1Mountain Hous&WH Application FormsWH-LA-ME Form -MASTER <br />-a- <br />