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A4u1N ! i 02�00 3" <br /> APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> < SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> Cfko�'+N`p FILE NUMBER: - - <br /> ETO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: *,. 'J+Ckle f - ,I,T.z Name: <br /> Address: ♦� a Address: <br /> -540C 21z <br /> Phone: Zv5 `j'3 (- to/ Phone: <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: <br /> " U 2 - }� Map Condition(s)of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: <br /> 2 rte F fio Ck 1 6 3 l s -V a .7 rv.fil �v Je irsti <br /> �. i '04, 'TD &9lt.ol.vJ' <br /> 1, rkug TL Le ` sr, r 3 <br /> 44. <br /> P i- <br /> 2. State the facts s owing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> o. le 0("e +P &ce-e,.I4tQo�dwa b <br /> we4 rpnVle r ero(v ' Jc nck ' sHe. <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 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, 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 the fpregoing foregoingapplication/sta-te-ments are true and correct. <br /> Print Name: f-Fkw. �. ►( '/�,}(,x„ Signature: lX/�`�^ Date:y 0 <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature. Date: <br /> F:\0EVSvctP1ann1ng Application FomMRevisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 10-19-04) <br />