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glyu)N I <br /> a° APPLICATION — USE PERMIT <br /> Q ;! SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> 9 <br /> 4 FILE NUMBER: UP- <br /> tIFORN <br /> Other <br /> Describe an items of historipl or archaeolo ical interest on-siie e: cemeteries or slruciures <br /> Describe any on-site or off-she sources of noise or vibration(e: .freeway noise,he equi ament,etc. : <br /> Describe any on-she or off-site sources of light of glare e. .parking lot lighting,or reifective materials used.: <br /> Describe,any on-site or off-site,source of odor e. .a ricukural wastes): <br /> Describe any displacement of people that will be caused by the project(e.g.numbers of people,housing units); <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 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,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 /> Print Name: 7om4emz signatur Date:/1 /S _ <br /> Print Name: Signature: Dale: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Dale: <br /> Print Name: Signature: Date: _ <br /> r--1DEVSVGTtanning Application FormslSile Approval.(RevSeC GM3 10) Page 5 of 9 <br />