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a 4UiM o APPLICATION - USE PERMIT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> .....ka` FILE NUMBER: UP- <br /> Describe <br /> P- <br /> De be any Hems of historical or archaeolorilcal Interest on-stte e. .cemeteries or structures): <br /> Describe en on-site or oN-stte sources of noise or vibration e. .freeway noise hea a ui ment,etc.: I <br /> I <br /> Describe an on-site or off-stte sources of light of glare e. . rkin lot li htin ,or reflective materials used <br /> Describe my on-site or off-site source of odor e. .a rimItural wastes): <br /> Describe an diso lacement of people that will be caused!?X the tomlect e. .numbers of people,housing units): <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 County arising from 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 propertys 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. A� <br /> Print Name: C7 A 1 r Signature: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FIDE SVQPhnwng Ap Ucalion Fcrmsms Pentyl.(Revise OM3-10) Page 5 of 9 <br />