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A� APPLICATiON - REVISIONS OF A PROVED ACTIONS <br /> { SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER-.'U-P-=-O- 1 4f11 0 <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: Name: R192flauZq�-2�4L <br /> Address: (6 94 - w Address: 4-1 a <br /> Phone: 2.6 -VC6 C11176 Oe, Phone: d4 GYJ <br /> PROJECT DESCRIPTION <br />+ Proposal <br /> Revision to: L)P c Map Condition(s)of Approval f, <br /> File No: <br /> i1. Description of the proposed Revisions: 11 <br /> 0 70 <br /> i <br /> i2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> 4 <br /> k ` <br /> I <br /> r <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> I, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and employees <br /> from any claim, action or proceeding against the County arising from the Owner/Agent's project. <br /> I, further, certify under penalty of perjury that I am (check one): <br /> 1A. Legal property owner(owner includes partner, trustee, grantor, or corporate officer)of the property(s) involved in <br /> this application, or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and <br /> i <br /> have been authorized to file on their behalf., and tha a' ication statements are true and correct. <br /> Print Name: Signature: Date: <br /> Print Name: Signat a <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:IDEVSM 121anning Application ForrrislRevisions of Approved Aebons.doc Page 2 of 2 <br /> (Revised 05-11-09) <br />