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a 1 f <br /> . - ' u l,v <br /> °P APPLICATION ;�USE PERMIT <br /> y: SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> r�•, -- ; FILE NUMBER: UP- <br /> Other <br /> Describie an items rrof''historical or archaeological interest on-site(e.g. cemeteries or structures): <br /> Describe an on-site or off-site sources of noise or vibration(e.g.freeway noise,heavy equipment, etc. : <br /> !v <br /> Describe an 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 AAsoiiurce of odor(e.g.agricultural wastes): <br /> tv <br /> Describe any displacement of eoryry le that will be caused by the project(e.g. numbers of 2eople, housing units): <br /> Iv <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> 1, 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 /> iLegal 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 th the foregoing application statements <br /> are true and correct. <br /> r,� <br /> Print Name: r(, AA� () Signature: 2( l Date 5 ��q <br /> Print Name: Signature: Date: J <br /> Print Name. Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F OEVSMplanrning Application Forms%Use Permit.(Revised 09-10-08) Page 5 of 9 <br />