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APPLICATIC USE PERMIT <br /> z SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> "40 •:� � FILE NUMBER: UP- <br /> Describe aff items of historical or archaeolboical interest on-site e .cemeteries or sbuckffes <br /> Describe any on-site or off-s€te sources of mise or vibration fe.g.h2"91 noise h2ffl OCI&M-8-21etc.). <br /> Describe a on-site or off-site sources of Dght of gLim Leq.pwiting lot Nhffrtg.or reAecdve materials used): <br /> Describe any on-site or off-site source of odor s. . dcutkn1 vrastes: <br /> NONE <br /> Descnbe arty displacement of 22o&that vrill be caused by the e. .numbers of houslEg units <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 <br /> employees from any 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 /> 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.,and that the foregoing application statements <br /> are true and correct. <br /> Print Narne: 19 C" signature: Bate: 0� <br /> Print Name: Signature: DOW: <br /> Print Name: Signature: Date: <br /> Print Name: signature: Date: <br /> Date. <br /> Print Name: Signature: <br />