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APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> R NO <br /> Tf7:13E+C(yF1PLEFiDBY-HE�APPLICANTPWORTGFiC> IG.THISAPPLICA7fOM1i <br /> Wrnerteifo^rrrlaGorr t�icanA <br /> Name: Name: <br /> Address: ftnfIorrrnt✓ationt <br /> cl Address: "(t'{�'J V <br /> +�n(�, , S, 3u IA -K • Ca , cfs3Da l <br /> Phone: — -{L_ Gott X01-11g(-376 Phone: D55— ctYI 11 G <br /> .Pr "at p �/ ('t <br /> Revision to: Ma Condition/s of Approval GX —'G <br /> File No: <br /> 1. Description of proposed Revisions: <br /> -<C _ CSC- <br /> 2. State the facts showing the than es in circumstances which make the subject conditions no longer aro riate or necessary. <br /> e A-tic. <br /> AUTHORIZATION SIGNATURES <br /> ONLYTHE OWNER.OF THE PROPERTY OR AN AUTHORIZED AGENT MAY F LE ANr 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 /> Legal property owner(owner includes partner,trustee,trustor,or corporate officer)of the <br /> property(s) involved in this application, or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's <br /> involved in this application and have been authorized to file on their behalf., and that the <br /> foregoing application statements are true and correct. <br /> fP <br /> rint Name: �'r`t-'tom 1��t-C-t_ Signature: ` r'I Date: <br /> rint Name: Signature: Date: <br /> inName: Signature: Date: <br /> rint Name: Signature: Date: <br /> print Name: Signature: Date: <br /> -2- <br />