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APPLICATI > 4 --- USE PERMIT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: UP- <br /> ;ir=o''R'� ¢ <br /> T <br /> Describe any items of Historical or amhaeo b i t interest on-site(eq-cemeteries or strud6res <br /> Describe any on-site or off-site'sources of noise or vibration e. .y noise,h i mend,etc-): . <br /> 0 <br /> Describe any on-site or offsite soumes of light 9f glare (e—parlqq lot lighting,or reflective materials used - /f'r <br /> Describe any on-site or off-site source of odor e. . cultural wastes): <br /> i <br /> Describe a d' acemerrt of that will be caused the ed e. .numbers of le,housin units): <br /> • 4 <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 <br /> employees from any claim, action or proceeding against the QwnerlAgenfs project.. <br /> 1.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 /> �b �1VXA . <br /> Print Name: Signature. Date- <br /> Print Name: Signature: Date: <br /> Print Name: Signature: _— Date: <br /> Print Name: Signature: Date- <br /> Print Name: Signature: Date: <br />