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APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> to s ats .akvxsw .?go- <br /> APPkICATION; <br /> OwtiaftaCortnaGoazn d, 5it'l A "ligan!"tnioimatian <br /> Name: n eJI'f X01- 60e-S- Name: e/—,// <br /> Address: LBO 2 IC o .� Address: L-L� W' <br /> Phone: Phone: <br /> �5' z�si y",m'A4rt l'SR.lixz`�E .Y7tn ,y. .• I <br /> J1,k' <br /> DESCRIPTION: <br /> Revision to SA - 199-91Z Map Condition/s of A pp roval <br /> File No: <br /> 1. Description of proposed Revisions: <br /> e E' urr <br /> 2. State the facts showing the changes In circumstances which make the subject conditions no longer aro riate or necessary. <br /> ea Semfn c e s e r <br /> s c oieo <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 /> 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 <br /> property(s) involved in this application,or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's <br /> involved in this application and have been authorized to file on their behalf., and that the <br /> foregoing application statements are true and correct <br /> Print Name: r 0 rf W Signatur : ____ ^.a,• doL <br /> Print Name: <br /> Print Name: signature: Data: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> -2- <br />