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MICR SUBDIVISION <br /> CAPPLICATION ! <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> A�., FILE NO: MS- <br /> AUTHORIZATION,'.SIGNATU RES''. .. <br /> ONLY THE OWNER OF THE PROPERTY OR AN°AU.THORIZED AGENT MAY FILE'AN APPLICATION: <br /> I, the OwnedAgent agree,to defend, indemnify, and hold harmless the County and its agents, officers and employees from any claim, <br /> 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, grantor, or corporate officer)of the property(s) involved in this <br /> application,or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and have been <br /> authorized to file on their behalf., and that the foregoing application statements are true and correct. <br /> Print Name: Allen S.Thomsen Signature: J 2A` CDate: <br /> Print Name: Thomas L.Thomsen Signature: Date: 4-Z"-7- <br /> Print Name: Kenneth J. Thomsen Signature, ~ Date: <br /> Print Name: Kathleen R. Reinstein Signatur A4 Dater <br /> Print Name: Signature: Date: <br /> r <br /> F:TEVSV5T1ammng Application FormsWinor SubdMsion(Rev. 12-08-04) Page 5 of 5 Job No 2005-20 <br />