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PLICATION ,- LOT LANE ADJUSTMENT <br />SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br />`\rRLr�oR��l1 <br />FILE NUMBER: <br />il ES f iy <br />ONLY T <br />HE`-oWiuE'�00 Ht�o�RTV'1n'i►wi';ne.t�r�;r�;.•:��:..�.� <br />-'.-� -•..�. ,..irr.,r+raA a..1 M. 1-AVJ# T'?ir'ILr; nmi ,AF PLICATIOIV. <br />f; 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 />1, 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 />APN 245-160-24 <br />Print Name: Daniel L. Myers Signature:IIIIII'`� / o <br />Date: <br />Print Name: Audre i T. Myers Signature: r� v <br />Date: <br />APN 245-160-31 <br />Arthur Van Groningen, Successor Trustee of the Arthur Van Groningen and Wllna Van Groningen By Pass Trust, U/AID <br />7/23/91, as amended <br />Print Name: Arthur Van Groningen Signature: �f <br />Successor Tru tee -/ Date: <br />Arthur Van Groningen, Trustee of the Arthur Van Groningen and Wilna Van Groningen Survivor's Trust, UTA1D 7123191, as <br />amended <br />Print Name: Arthur Van Groningen, Signatur��"�� � <br />Trustee ��� 4 Dater <br />Arthur Van Groningen, Successor Trustee of the Arthur Van Groningen and Wllna Van Groningen Marital Trust, U/AID 7/23/91, <br />as amended <br />Print Name: Arthur Van GroninAenti �� / F � <br />Signature: ��.. Dater /c <br />Successor Trustee - / <br />;='\0eVSVC\Piannin9 Application Forms\ Page 3 of 3 <br />Lot Line Adjustment.doc. (Revised 6-4-04) Job No 2010-31 LLA.doc <br />