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F <br /> a�,ql APPLICATION <br /> v — SITE APPROVAL <br /> X PRIVATE RIGHT OF WAY -ANTIQUATED-SUBDIVISION <br /> . <br /> SAN.JOAQUJN COUNTY C�3fViiirtUFviiTY D1 iiELOPMEN�` C]II PARTMENT <br /> FILE-:NUMBER: SA= <br /> t � A. <br /> F <br /> #hz �� y3tdS roanFIRM <br /> a"? (5an kesSN � z- <br /> FDesedbe <br /> �n items of historical or archaeolo 1calJnterest.on-site;:e: ,cemeteries,or,structures :n ors Ite or off-site sources.of xlbise or vib-ration e.d,ft eeirvay,noise,he ui ;tient;;etc. : s7't�f <br /> Describe any on-site or off--site sources of light of glare e. .paridng.lot lighting,or reflective materials used): <br /> Describe any on-site or off-site source of odor e. .agricultural wastes): <br /> Describe any displacement of people that will be caused by the proiect e. .numbers of people, housing units): op4 '' <br /> i <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT'MAY FILE AN APPLICATION. <br /> I, the Owrier/Agent agree, to defend, indemnify, and void harmless the County and its agents, officers and <br /> employees from any claim, action or proceeding against the OwneriAgent's project_ <br /> a <br /> I,further, certify under penalty of perjury that I am (check one): <br /> 0,Legal property owner(owner includes partner, trustee, trustor, or corporate.officer) of the property(s) <br /> involved in this application, or <br /> El Legal agent (attach proof of the owner's consent to the application of the property's involved in this <br /> I <br /> application and have been authorized to file on their behalf.,and that the foregoing application statements <br /> are true and correct. <br /> Print Name: r J?M Signature: a O� <br /> bate: � � i <br /> 4. <br /> Print Name: r ✓ Signature: Date: <br /> Print Name: Signature: Date: d <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:0EVSV0Planning Application FormstSite Approval) Page 5 of 7 <br /> POvalle Right of Way.(Revised4-2-03 <br />