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APPLICATION - DWELLING <br /> CLUSTER <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: DC- <br /> School Service Fire:Protection Service <br /> Service Provider Distance to ElemSchool Service Provider Distance to Fire Station <br /> Stockton Unified 2 miles Montezuma 2 miles <br /> Existing Roads <br /> Road/Street 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 /> 1, 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 /> 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 /> E application and have been authorized to file on their behalf., and that the foregoing application statements <br /> are true and correct. / <br /> X �C &Z Date: f' �'Z ^ .,G('� <br /> Print Name: �� Signature: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> I <br /> FADEVSVOPlanning Application Forms Page 4 of 6 <br /> Dwelling Cluster(Revised 5-11-09) <br /> I <br />