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USE PERMIT <br /> APPLICATION <br /> k <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> % <br /> FILE NUMBER UP <br /> Other <br /> Describe any items of historical or archaeological interest on-site (e.g. cemeteries or structures): <br /> Describe any nqite or off-site sources of noise or vibration (e.q. freeway����L <br /> _ <br /> —----------- <br /> Describe U1qn-site or off-site sources of fight "are e. <br /> _parking lot IWtting, orreflective materials used <br /> Describe any on-site or off-site source of odor�e.g agricultural waste_____ <br /> Describe any displacement of people�hat will be caused by the pr <br /> ...............--------- <br /> .............. AUTHORIZATION SIGNATURES <br /> ................ <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 /> 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 /> 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 /> —J <br /> Print NRme:, ate: ll <br /> —(;.2"p-0 gr <br /> . ......... ......- <br /> Print Name: ................ Signature: ..... ............... Date: — <br /> Print Name: Signature: Date: <br /> Print Name: ............................ Signature: Date: <br /> Print Name: ..................... Signature: Date: <br /> ........... <br /> F.1DEVSVC%P1,3n.7ing AnplicaVcn TOUrSU J$P Pe.TfTlit (Revised 05-11-09) Page 5 of 9 <br />