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o�IN <br /> c APPLICATION ® USE PERMIT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> .fie. '�`•, <br /> • cP. FILE NUMBER: UP- <br /> 9�%FO-RC1 <br /> Other <br /> Describe any items of historical or archaeological 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 /> Describe any on-site or off-site sources of light of glare(e.g.parkinglot lighting, or reflective materials used): <br /> Describe any on-site or off-site source of odor(e.g. agricultural wastes): <br /> Describe any displacement of people that will be caused by the project(e.g. numbers of people, housing units): <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 County arising from the Owner/Agent's project. <br /> I, further, certify under penalty of perjury that I am (check one).- <br /> Legal <br /> ne):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 /> -57�Print Name: ��, *wl i �h Signature: Date: <br /> Print Name: _0Ct ikk L Signature: Date: �� <br /> Print Name: Signature: _. _ Date: <br /> Print Name: Signature: _ _ Date: <br /> Print Name: _ Signature: __ Date: <br /> f AI)F VSVCAPL,-i,mn,q Apphcahn'I FonnsAI_I:., I Iernlit.(I;,,Visr t 0?03 10) 5 of 9 <br />