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APPLICATION -. SITE APPROVAL <br /> up SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> PA- 1 1 TO 0 2.1 <br /> . FILE NUMBER: SA- <br /> Other <br /> Describe any items of historical or archaeological interest on-site Wa.cemeteries or structures): <br /> s <br /> Describe any on-site or off-site sources of noise or vibration(e.g.freewa n Ise,heavy u1 ment,etc.): <br /> l <br /> Describe any on-site or off-site sources of light of glare e. .parking lot lighting,or reflective materials used): <br /> Describe any on-site or off-site source of odor e_ .agricultural wastes): — � <br /> Describe any displacement of people that will be caused by the project(e.g.numbers of people,housing units): <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> 1, 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 /> egal property owner(owner includes partner, trustee, trustor, or corporate officer) of the property(s) <br /> involved in this application, or <br /> regal 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 /> Print N. - Jt' Signature: i I <br /> Print Name:_ 1�kj a T ell 11 !L4,1 k, L I,J3, Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> r-:m)evsvcwienninq AWi�wfion Fonw'.S ie rpm+.(Revised 02-03-10) Page 5 of 9 <br />