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APPLICATION — SITE APPROVAL <br /> Iw` ' SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: SA- <br /> Outer <br /> Describe any items of Nstorical or archaeolty4ical Interest on-site(e.g.cemeteries or structures): <br /> Describe any on-site or off-site sources of noise or vibration(e.g.freeway noise heavy equipment,etc.): <br /> Nus <br /> Describe arty on-site or off-site sources of light of glare e. .parking lot lighting,or reflective materials used <br /> Describe any on-site or off-site source of odor(eg.agricultural wastes): <br /> r �ola <br /> Describe any displacement of people that will be caused by the projed e. .numbers of people,housing units): <br /> AUTHORIZATION SIGNATURES <br /> ONLY E O ER OF Tt PROPERTY Qg AN AU ORIZED 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 County arising from 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 /> ❑ 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 th regoing application statements <br /> are true and correct. <br /> Print Name: 1 c u lis CZ o Signature: Date:�� <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: — _ Signature: Date <br /> Print Name: Signature: --- Date: <br /> POEVSVOPlanning Appl cat on Forms\S to Approval (Revised 02-03-10) Page 5 of 9 <br />