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APPLICATION - <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> - � � FILE NUMBER: <br /> Other <br /> Describe any items of historical or archaeological interest on-site e. .cemeteries or structures): <br /> Describe any on-site or off-site sources of noise or vibration e. .freeway noise,heavy equipment,etc. : <br /> Describe any 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(e.g.agricultural wastes): <br /> Describe any displacement of people that will be caused by the project e. .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 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 <br /> -Tand <br /> �correct. <br /> Print Name: .+--�r�lr.� 3trr�r� Signature: Date: �3-7- 13 <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F.\DEVSVCtPIanning Apphc hon Forms\Use Permit.(Revise 02-03-10) Page 5 of 9 <br />