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APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> t SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: - <br /> Cr�okH <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: L N Name: <br /> Address: Address: <br /> Phone: Phone: <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: Map Condition(s)of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: ' <br /> 2. State the fads showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY 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, furt r, certify under penalty of perjury that 1 am (check one): <br /> Legal property owner(owner includes partner, trustee, grantor, or corporate officer)of the property(s) involved in <br /> this application, or <br /> ❑ Legal agent(attach proof of the 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 theforegoing application statements are true and correct.. <br /> Print Name:)Dr-J (�� ( I Signature: Dated: — <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FMEVSVOPlanning Application Forrns\Revisiws of Approved Actions.doc Page 2 of 2 <br /> (Revised 05-11-09) <br />