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APPLICATION - <br /> ` SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NO: <br /> �.. <br /> \5�/FORN`P <br /> Other <br /> Describe any items of historical or archaeological interest on-site(e.g. cemeteries or structures): <br /> NIA - <br /> Describe any on-site or off-site sources of noise or vibration(e.g.freeway noise, heavy equipment, etc.): <br /> NIA <br /> Describe any on-site or off-site sources of light of glare (e.g. parking lot lighting, or reflective materials used): <br /> N/A <br /> Describe any on-site or off-site source of odor(e.g. agricultural wastes): <br /> N/A <br /> Describe any displacement of people that will be caused by the project(e.g. numbers of people, housing units): <br /> N/A <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 /> ! further certify, under penalty of perjury, that I am (check one): <br /> I I <br /> ❑ Legal property owner (owner includes partner, trustee, grantor, or corporate officer) of the property(s) <br /> involved in this application, or <br /> a <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 <br /> statements are true and correct. <br /> Print Name: DA20i✓ Signature: %� - L� Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FOEVSVS\Planning Application Forms\Site Approval(Revised 6-03-04) Page 4 of 4 2012-128 Site Approval <br />