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APPLICATION - LOT LINE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> \ ti FILE NUMBER: <br /> j 4it;;oRa <br /> i <br /> 1 <br /> _ A'LTFHQRIZATI ¢ I �IGNATUREtS <br /> s s EF f f�,.'c 3 r',c;:. Aa'''F `.-e'.7H.{` '" ; <br /> ONLYT-,,iE OWNER OF 'T,H_E PROPERti�Y QR A'N,.A ITHORIZED:AGENT MAY FILE,AN;iAPP,LICATION: <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 /> ❑ 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 /> i <br /> i <br /> APN 201-160-09, 10, 17, 18 AND 19:Van Groningen&Sons, Inc. r <br /> Print Name: ban Van Groningen Signature: Date: 7 �2 <br /> APN 203-050-15: Daniel Allen Van Groningen,Trustee and Patricia Van Groningen,Tru ee of! a Van Groningen Family <br /> Trust UTAID August 8, 1991,as Amended <br /> Print Name: Daniel Allen Van Groningen. Signatur . F te:_ -ZZ <br /> � <br /> Trustee �. <br /> Print Name.: Patricia Van Groningen; _ _ Signature: dx ate: 7`Z2--14 <br /> Trustee <br /> 1 <br /> i <br /> i <br /> 1 <br /> i <br /> 1 F:0EV5VCTianning Application Formsl Page 3 of 3 Job No 2011-124 LLA 1 <br /> Lot Line Adjustmenl.doc.(Revised 6-4-04) <br />