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APPLICATlvN - USE PERMIT <br /> 1 '� '•.OG <br /> W ;{ SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> �d FILE NUMBER: UP--. <br /> FOF:a <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.g.freeway noise,heavy equipment, etc. : <br /> •�r� near <br /> Describe any on-site or off-site sources of light of glare(e.g. parkinglot lighting,or reflective materials used): � <br /> ane. <br /> Describe any on-site or off-site source of odor(e.g.agricultural wastes): <br /> Describe any displacement of people that will be caused by the 2roject(e.g.numbers of people, housing units): <br /> 0 r) <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 <br /> employees 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, 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: MU J"YM i) n KIWI Signature: � Date: —2LZ <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:0EVSVCXP1ann1ng Application FormslUse Permit.(Revised 1-2-03) Page 5 of 9 <br /> t <br />