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,5 01 : 05P John TaU1lor YC 1 [ 530) 671 -590 <br /> ' F - 2 <br /> /22Y05 J3: 26 FAa 209 942 0 Siegfried L•ns L23uu-3 <br /> APPLICATION - <br /> SANJOAOUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMEI T <br /> FILE NUMBER: X,'Pz <br /> MW W—M <br /> Describe any items of historical or archaeological interest on-silo e. .cemeteries or structures): <br /> None <br /> Describe any or-site or otl rile sources of noise or vibration(e.g.freeway noise,heavy equipment.etc.): <br /> None <br /> Describe any on-site or orf-site sources of light o1 glare e. aiVing lot fi htin ,or reflective materials used): <br /> General yard 1ia <br /> Describe any on-site or off-sfie source of odor(e.g.agricultural wastes-. <br /> None <br /> Describe any displacement or people that will be caused by the project(e.g.numbers of peDpte,housi units: <br /> None <br /> AUTHORIZATION- GNAU i�S�- V <br /> x_ 1. T�)l tQyVtiIEFT QF THE PROPERTY OR AN-AUTH0RIZED:AGENT-MAY'... Mr.- _l�'i O.. <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 /> 1, further,certify under penally 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 th application of the property's involved in this <br /> application and have been authorized to file on their b alt.,and that the foregoing application statements <br /> are true and correct. <br /> Print Name: Signature: Date: L) CU <br /> Print Name: Signature: Date: <br /> Print Nemo: signature: Dale: <br /> Print Nome: Signature: Date: <br /> Print Name- Signowre_ Date: <br /> F_XDEVSVCZPInnnlnq APO-c-lbn FormnlV.0 Pruett.(A—;S.d X03-04) Page 5 of 9 <br />