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IF c° APPLICATION -- USE PERMIT c l SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT FORa, FILE NUMBER: UP- Other . Describe an items of historical or archaeolo Wal interest on-site e. .cemeteries or structures : None known. Project won't affect any items of historical or archaeological interest. Describe an on-site or off-site sources of noise or vibration(e.g. freeway noise, heavy equipment, etc. : No changes in any sources of noise from the project. f Describe any on-site or off-site sources of light of glare (e,.q.parkinglot li htin , or reflective materials used): No changes in any sources of li ht from the ro'ect. Describe an on-site or off-site source of odor e.g. a ricultural wastes): No chap es in any sources of odor from the erolect Describe an displacement of people that will be caused by the ro'ect(e.g. numbers of 2eople, housing units): No dis lacement of eo le will be caused by the project. AUTHORIZATION SIGNATURES ONLY THE OWNER OF THE''PROPERTY�OR-AN AUTHORIZED AGI NT MAY FILE..AN APPLICATION. I, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and employees from any claim, action or proceeding against the County arising from the Owner/Agent's project. i, further, certify under penalty of perjury that I am (check one): x Legal property owner (owner includes partner, trustee, trustor, or corporate officer) of the property(s) involved in this application, or ❑ Legal agent (attach proof of the owner's consent to the application of the property's involved in this application and have been authorized to file on their behalf., and that the foregoing application statements are true and correct. Print Name: O Co rf �, Signature: Date: /10 Print Name: Signature: Date: Print Name: Signature: Date: Print Name: Signature: Date: Print Name: Signature: Date: F:IDEVSVC1PIanning Application FormsltJse Permit.(Revised 02-03-10) Page 6 Of 9 4� i