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APPLICATION SITE APPROVAL <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 4CtFO��`P <br /> FILE NUMBER: SA- <br /> MOMI, <br /> 9 Other`Rims of historical or archaeolo ical interest on-site e. , cemeteries or structures : <br /> on-site or off-site sources of noise or vibratione. .freewa noise, hea a ui merit, etc./Zon/-kite or off-site sources of li It of tare e. arkin lot li htin ,or reflective materials used : <br /> lon-site or off-site source of odor e. .a ricultural wastes_ <br /> Describe an dis lacement of people that will be caused b the r9ject e. . numbers of eo le, housm units): <br /> o -r <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <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 an (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 /> ❑ 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: a�.�.r c.k�a7 Signature: Date: Z--/r aS <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F 0EVSVC1P1anning Application Formstsite Approval.(Revised 1-3-03) Page 5 of 9 <br />