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ra)f �N, ih <br /> oe <br /> APPLICATION — REVISIONS OF APPROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER:FOit�\ <br /> TO 13E.COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Applicant Information <br /> Name: Name: . <br /> Address: 11016, Address: P©. box 11 <br /> l-00 2 0 too, cnr 9 m l <br /> Phone: - 7-q]4 Phone: — Z�32 <br /> PTION <br /> Revision to: Map Condition(s)of Approval <br /> File No: PR-12.©D I9.(� <br /> 1. Description of the proposed Revisions: <br /> Sn) F P fx F 4e)m tcx) Per)R_6 To 1/45 <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> RU0 5 LIKE <br /> do l <br /> ,��ZATION SIGNATURES <br /> SAN 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 employees <br /> from any claim, action or proceeding against the County arising from 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, grantor, or corporate officer)of the property(s) involved in <br /> this application, or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and <br /> have been authorized to file on their behalf., and that the for applicalr6n statements are true and correct. <br /> Print Name: ' Signature: Date: <br /> Print Name: Wa` Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FADEVSMPlanning Application FonnsRevisions of Appmved AcUons.doc Page 2 of 2 <br /> (Revised W11-09) <br />