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APPLICATION "SITE APPROVAL <br /> ` PRIVATE RIGHT OF WAY - ANTIQUATED SUBDIVISION <br /> SAN JOAOUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: SA- <br /> Other <br /> Describe any items of historical or archaeological interest on-site e. .cemeteries or structures): <br /> NowE <br /> Describe any on-site or off-site sources of noise or vibration e. .freeway noise, heavy equipment, etc. : <br /> O wi <br /> Describe any on-site or off-site sources of light of glare(e.g. parkinglot lighting,or reflective materials used): <br /> ti0MC <br /> Describe any on-site or off-site source of odor e. .agricultural wastes): <br /> ki Z)rJ <br /> Describe any displacement of people that will be caused by the project(e.g.numbers of people, housing units): <br /> NDOC. <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 /> Q 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 /> 2/orPPrint Name: 5��.(e,r _ C.Na..k-.a Signature: Date: & /?-/Os— <br /> Print <br /> rint Name: JJ,J,.i,�++' (/16c.Aioo Signature: ate: Wz oy <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:tDEVSVC\Planning Appr"tim Fo slSite Approval) Page 5 of 7 <br /> Private Right of Way-(Revised4-2-03 <br />