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°p4U(N APPLICATION - LOT LINE ADJUSTMENT SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT FILE NUMBER: �rFOR AUTHORIZATION SIGNATURES ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. I, the Owner/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and employees from any claim, action or proceeding against the Owner/Agent's project. I, further, certify under penalty of perjury that I am (check one): ® Legal property owner (owner includes partner, trustee, trustor, or corporate officer) of the property(s) involved in this application, or ❑ Legal agent (attach proof of the owner's consent to the application of the property's involved in this application and have been authorized to file on their behalf., and that the foregoing application statements are true and correct. APN 228-080-09 Henry Mark Van Groningen and Debra Van Groningen, Trustees of the H.M. &D.L.Van Groningen Family Trust, U/A/D September 26, 2007, as Amended Print Name: Henry Mark Van Groningen. Signature: Trustee Print Name: Debra Van Groningen. Signature(; Date: S 1 Trustee APN 228-080-10 Dale A.Van Groningen and Patricia J.Van Groningen,Trustee of the D&P Van Groningen Family Trust U/A/D 1/14/08,as Amended; Print Name: Dale A.Van Groningen, Signature:, L) - Date: 12-I5 Trustee Print Name: Patricia J.Van Groningen, Signature. Date: L 1 Trustee Daryl Kent Van Groningen and Arlys F.Van Groningen,Trustees of the Daryl Kent and Arlys Van Groningen Family Trust, IJ/A/D 7/11/07,as Amended; Print Name: Daryl Kent Van Groningen, Signature: 1" " `� Date:?-)q- Trustee ate:?-)q-Trustee Print Name: Arlys F.Van Groningen, Signatu (/ems, ;e ` > Date: F//7�/0 Trustee Henry Mark Van Groningen and Debra Van Groningen,Trustees of the H.M. & D.L.Van Groningen Family Trust, U/AID September 26, 2007,as Amended Print Name: Henry Mark Van Groningen, Signature: Trustee Print Name: Debra Van Groningen. Signature: n ( !Gl( Date: I l� Trustee FADEVSMfolanning Application Forms\ Page 3 of 3 Job No 2018-181 LLA-1 Lot Line Adjustment.doc.(Revised 6-4-04)