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COO <br /> � APPLICATION ,- SITE APPROVAL <br /> . ..ot PRIVATE RIGHT OF WAY - ANTIQUATED SUBDIVISION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: SA- <br /> Other <br /> Describe an items of historical or archaeological interest on-site e. .cemeteries or structures <br /> Describe an on-site or off-site sources of noise or vibration (e.q.freewaynoise, hea equipment, etc. <br /> Describe an on-site or off-site sources of light of glare (e.g. parkinglot lighting,or reflective materials used <br /> Describe an on-site or off-site source of odor(e.g. agricultural wastes <br /> t� <br /> Describe an dis lacement of beople that will be caused by the 1)r-:--' e. . numbers of eo le, housin 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 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 /> El 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 and correct. <br /> (n� G �� Date: I <br /> Print Name: +"�A.�r sl M� � Signatu mama — <br /> Print Name: /C.-. <br /> S�t w pvw Signature: Date: J'1 <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> . •­­,....,F,. ,lite Aparovap Page 5 of 7 <br />