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°q4°t APPLICATION - USE PERMIT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> __,j FILE NUMBER: UP- <br /> q(i}'oR`� <br /> Other <br /> Describe any items of historical or archaeological interest on-site e. .cemeteries or structures): <br /> Describe any on-site or off-site sources of noise or vibration e. .freeway noise heavy equipment,etc.): <br /> N41 <br /> Describe any on-site or off-site sources of light of glare e. .parking lot lighting,or reflective materials used): <br /> Describe any on-site or off-site source of odor e. .agricultural wastes): <br /> Describe any displacement of people that will be caused by the ro'ect e. .numbers of people, housing units): <br /> AUTHORIZATION SIGNATURES ER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> [ONLY <br /> t agree, to defend, indemnify, and hold harmless the County and its agents, officers and <br /> ny claim, action or proceeding against the Owner/Agent's project. <br /> nder 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: /( Signature: 7^ Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F;WEVEIMPIanning Application Forms\Uw Permit.(Revised a-03-04) Page 5 of 9 <br />