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°- c APPLICATION — USE PERMIT <br /> k z i <br /> V :A SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> a..: ...,, . FILE NUMBER: UP- <br /> {�F'OJ <br /> f <br /> Describe any items of historical or archaeological interest on-site e. .cemeteries or structures): <br /> Describe any on-site or off-site sources of noise or vibration(e.g.freeway noise,heavy equipment,etc. : <br /> Describe any on-site or off-site sources of li ht of glare e. .parking lot lighting,or reflective materials used): <br /> Describe any on-site or off-site source of odor e. .agricultural wastes): <br /> d <br /> Describe any displacement of. eo le that will be caused by the project(e.g.numbers of people,housing units): <br /> M <br /> f <br /> Z# <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 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 /> �( `' r <br /> Print Name: 1\�����i �� t��'ly Signature: � Date: �� Z� <br /> I Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> a Print Name: Signature: Date: <br /> t <br /> Print Name: Signature: Date: <br /> r:1DEVSVMPlanning Apprication Forms\Use Permit.(Revised 02-03-10) Page 5 of 9 <br /> 1 <br />