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r <br /> APPLICA� ION -` S" ITE APP� x APPROVAL <br /> a .. <br /> SAN .lOAQUfN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: $A- <br /> . <br /> }, <br /> .. ...• ..,-f.r'_er .. . ... r?, 71.,a..i.: ..,na;:.r 1i.•.>.: -1.J,Y�k.,- I x�",us,.k i �,fF e -, SR ,�y'�ty �� d I �S r"; 1 rti�r''. <br /> Describe an items of historical or archaeolo ical interest on-site e: .,cemetenes or structures. <br /> Describe an on-site or off-site sources of noise or vibration (e.g.freeway noise, heayy a iii rnent, <br /> r..d©tJG <br /> Describe an on-site or aff-site"sources of light of glare e. arkin lot fi htfn ,or re fiecfive materials used <br /> p4v�, <br /> Describe an on-site or off-site source of odor(e.g. agricultural wastes,- <br /> 61W <br /> C <br /> Describe an displacement of people that will be caused by the proiect(e-n- numbers of people,le, housin units <br /> 00 cvg__� <br /> AaUTHORI.."TON SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> 1, 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 y(s) <br /> Q`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 Name: _ �t?vy,. zl,gJl, .. <br /> _ Signature: <br /> Print Name: Date: 11 <br /> Signature: <br /> Print Name: Date: <br /> Signature: <br /> Print Name: Date: . <br /> Signature: <br /> Print Name: Date: <br /> Signature: <br /> Date: <br /> DEVSVC\Plarining Appiicatiorn ForrnslSite Approval.(Revised 1-3-03) Page <br /> . 5of9 <br />