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APPLICATION - USE PERMIT <br /> y SAN JOAQUIN COUNTY COMMUNIT 1EVELOPMENT DEPARTMENT <br /> c4�lFP FILE NUMBER: UP- - <br /> it Other <br /> Describe any items of historical or archaeological interest on-site(e.g.cemeteries or structures): NON 4 <br /> Describe any on-site or off-site sources of noise or vibration (e.g.freeway noise, heavy equipment, etc. : rAA I /Q <br /> Describe any on-site or off-site sources of light of glare(e.g. parkinglot lighting,or reflective materials used): t44ON E <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 project(e.g. numbers of people, housing units): NONE <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: t A1/f 1 IM 1492 Signature: — Date: 10 12 <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:\DEVSMPlanning Application Forms\Use Permit.(Revised 1-2-03) Page 5 of 9 <br />