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°PQuI" APPLICA nON - REVISIONS OF APPROVED ACTIONS <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> �9�1F0Fit1\P FILE NUMBER: <br /> TO BE COMP ETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Informatio Applicant Information <br /> Name: - _ j, Name: <br /> C. 1 • <br /> Address: - <. Address: <br /> Phone: Phone: <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: Map Condition(s) of Approval ,e <br /> — - /{� <br /> File No: , + i � (J <br /> 1. Description of the proposed Revisions: <br /> OL � <br /> 2. State the facts showing the chaliges in circumstances which make the subject condition(s)no longer appropriate or necessary- <br /> e <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE ROPERTY 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 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 in ludes partner, trustee, grantor, or corporate officer) of the property(s) involved in <br /> this application, or <br /> ❑ Legal agent(attach proof of th 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 foregoing application statements are true and correct. <br /> o- <br /> Print Name:_ `i %r'.Gf Signature: �,r�'02V_ Date: <br /> Print Name: " 1 i 1 r i Signature: �'� JAG . ' Date: :;L _,Z3 <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:\DEVSVC\Planning Application Forms\Revisions of pproved Actions-doc Page 2 of 2 <br /> (Revised 05-11-09) <br /> E <br /> i <br />