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°RQUFM APPLICATION - USE PERMIT <br /> w. <br /> :< SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> �`'• FILE NUMBER: UP- <br /> 4 '1 F! <br /> ift ti� � % a y� i$, d r�rc Ex pr: <br /> r Oflier E f s° ; <br /> �..,s <br /> Describe any items of historical or archaeological interest on-site(e.g.cemeteries or structures): <br /> None <br /> Describe any on-site or off-site sources of noise or vibration(e.g.freeway noise, heavy equipment,etc. : <br /> None <br /> Describe any on-site or off-site sources of light of glare(e.g. parkinglot li htin , or reflective materials used): <br /> None <br /> Describe any on-site or off-site source of odor(e.g. agricultural wastes): <br /> None <br /> Describe any displacement of people that will be caused by the project(e.g. numbers of people, housin units): <br /> None <br /> AUTHORIZATION SIGNATURES f w ,' " <br /> .,.._.. ,x. .. <br /> ` , br a <br /> ONLYk,THE OWNER,;QF,TH PRQPERTWPR, AN AUTHORIZED AGENT MAY`FILE AN APPI_lCAT16N, > ` <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 /> I, 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 /> ❑x 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 /> 1-1, - <br /> Print Name: Signature: � Date: � <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FMEVSVC%Planning Application FormsWse Permit.(Revised 6-03-04) Page 5 of 9 <br />