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°Pa" " c APPLICATION - REVISIONS OF APPROVED ACTIONS 1 <br /> y SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: <br /> �IFOR� <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: S ��A ( �{ZP (S�t Name: �t <br /> Address: U. a�3a! Address: 0 , p 10 <br /> L-&..- ' t 3 l <br /> fPhone: Phone: ZQc ZS' gl� <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: D Map ;�2a g- QL t)- Condition(s) of Approval <br /> File No: t <br /> 1. Description of the proposed Revisions: <br /> —t W 1 t c, <br /> n o of l V e - �-r) w <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> Nt 0 <br /> LD 1A 0 <br /> r (/fir <br /> -t- a o-V i <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 employees <br /> 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, 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 th eqoing application statements are true and correct. <br /> Print Name: h4U2.� Signature: Date: <br /> Print Name: V i S Signature: J Date: L t I I S <br /> Print Name: Signature: Date: <br /> { Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FADEVSMPlanning Application Forms\Revisions of Approved Actions doc Page 2 of 2 <br /> (Revised 05-11-09) <br />