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APPLICATION - DWELLING CLUSTER <br /> h; { SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> ;li=oRa�� FILE NUMBER: DC- <br /> Sch <br /> oolervice Fire Protection Service <br /> Distance to Elem <br /> School Service Provider Distance to Fire Station <br /> 2 miles Montezuma <br /> 2 miles <br /> ExistinRoads <br /> t Name R.O.W.Width Pavement Width Curb/Gutter Sidewalks <br /> Ralph Avenue 60' 40' Yes❑ No® Yes❑ No <br /> B Street 80' 80' Yes® No❑ Yes® No❑ <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 County arising from the Owner/Agent's project. <br /> 1, 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 /> s <br /> involved in this application, or Y( <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: ' <br /> Date. f ^� <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> FADEVSVC1PIann1ng Application Forms Page 4 of 6 <br /> Dwelling Cluster(Revised 5-11-05) <br />