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07/22/05 20:34 FAX 847 4807981 HENLEY MGNT CO #555 2005 <br /> 4t4 APPLICATION - SITE APPROVAL <br /> P <br /> :s SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> ff FILE NUMBER: SA-_ — <br /> Dfh�r'` <br /> Describe any items of historical or archaeological interest on-slte e. .cemeteries or structures): <br /> N lik <br /> Describe any on-site or off-site sources of noise or vibration e. .freewa noise heavy equipment,etc): <br /> N /A <br /> Describe any on-site or off-site sources of light of glare(e.g. parkinglot li htin ,or reflective materials used): <br /> LIA <br /> Describe any on-site or off-site source of odor(e.g. a rioultural wastes): <br /> Describe any displacement of peoplethatwill be caused b the ro'ecl e. . numbers of people,housing units <br /> WIA <br /> AUTHORISATION+SIG NATURES <br /> ONLY TF1E'0WNER L3F;-THE FRC PERTY OR AN AUTK0RIZaID.AG):NT 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 /> 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 owners 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 /> Print Name: C14QIr5 7-1f= Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: a Signature: Date: <br /> Print Name: 1V4MW4AWPk I"AiAb�"81 -&&fc.5ignature: of Date: <br /> Print Name: lt)s"'*4'K R.LEwdl.Ul.r4J'M1• Signature: -,- Date: <br /> F.IDEVSVC+ tanning Appllaenon ForrraXsile Approval.(Revised 6-0 N) Page 5 of 9 <br />