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APPLICATION - SITE APPROVAL <br /> < SAN JOAQUIN 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 /> Describe any on-site or off-site sources of noise or vibration e. .freeway noise,heavy equipment,etc-): <br /> Describe on-site or off-site sources of light of glare a tit lighting,or reflective materials used): <br /> Describe any on-site or off-site source of odor e. .agricultural wastes): <br /> Describe any dis lacement of people that will be caused by the project e. .numbers of people,housing units): <br /> e— <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 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 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 Name: i ��rC ,�L�.�r�tS Signature: ` [4, ( CRIc�'y" Date:_�Zl. <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F.VEVSVC\PlanniN Application Formbl&te Approval.(Reviwd 02-03.10) Page 5 of 9 <br />