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APPLICA-�JN – REVISIONS OF APPROVED ACTIONS <br /> 2: y <br /> y SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> :c4 FILE NUMBER: —f <br /> .eoliLFrvpLl r�srtc�t I� <br /> t rta <br /> Name: ` Name. Pr (9( l <br /> Address: J(,0 ''✓o(QJ �'(y� G-r Address: fQ (Q� <br /> EC&Ao c `C5 Z/1 <br /> Phone: Phone: 2 q s`54-2` s:2— <br /> rRm <br /> ision to: A,— Map Condition(s)of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: <br /> ga& s' 2 k4b bbt t , <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> �L <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 employees <br /> 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, grantor, or corporate officer)of the property(s)involved in <br /> this application, or <br /> Legal agent(attach proof of the owner's consent to the appl c tion of the property's involved in this application and <br /> have been authorized <br /> rrlItolI file on their behalf., and that the f goingapplication statements are true and correct.. <br /> l <br /> Print Name: W, �tM,(,`l l-C Signature: Date: 12-(dor"O r <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:\DEVSVC\Planning Application Fonns\Revisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 10-19-04) <br />