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APPLICATION - CERTIFICATE OF COMPLIANCE <br /> ( l SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> ci FILE NUMBER: CC- <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Engineer/Applicant Information <br /> Name: Susan Balogh / Jean Kent Name: Baumbach & Piazza, Inc. <br /> Address: P.O. Box 265 Address: 323 W. Elm St. <br /> Wallace, CA 85254 Lodi, CA 95240 <br /> Phone: (209) 763-5253 Phone: (209) 368-6618 <br /> Property Address: 19625 N . Southworth Road, Wallace CA <br /> Assessor Parcel Number(s): 023-260-01 <br /> PROPERTY HISTORY <br /> Give a history of the parcel (when created, by whom, any boundary modifications, ownership record, etc.) and any building <br /> construction history that may have a bearing on the parcel: <br /> This request is to comply with the conditions of a Parcel Map waiver. The resulting parcels are not less than 40 acres, conform with <br /> the General Plan and other County Ordinances. There will be no adverse effect on the environment. <br /> CO a"t � )G ✓! CC <br /> to <br /> ONLY THE OWNER OF TH JT MAY FILE AN APPLICATION . <br /> I, the Owner/Agent agree, to del )nd its agents, officers and employees <br /> from any claim , action or proceec <br /> I , further, certify under penalty of <br /> ® Legal property owner (owner includes partner, trustee, trustor, or corporate officer) of the property(s) involved in this <br /> 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 f going application statements are true and correct. <br /> Print Name: Susan f34do,q 'k Signature: Date: '>/jt t <br /> Print Name: Sec, n lien,+ Signature: !r . Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Si nature: Date: <br /> FADEVSVCkPlanning Application Forms\Deviation.doc. (Revised 6.03-04) Page 2 of 2 <br />