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Y <br /> 7. APPLICATION - SITE APPROVAL <br /> PRIVATE RIGHT OF WAY — ANTIQUATED SUBDIVISION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> - FILE NUMBER: SA- <br /> Other <br /> Describe any items of historical or archaeological interest on-site(e.g.cemeteries or structures): <br /> i <br /> r <br /> Describe any on-site or off-site sources of noise or vibration (e.g.freeway noise,heayy equipment,etc- : <br /> dIV <br /> i <br /> Describe any on-site or off-site sources of light of glare(e.g.parkinglot lighting,or reflective materials used): <br /> ANG= <br /> Describe any on-site or off-site source of odor(e.g.agricultural wastes): <br /> t <br /> Describe any displacement of people that will be caused by the project e.g.numbers of peppie,housing units <br /> MQ AIE <br /> AUTHORIZATION SIGNATURES <br /> l 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 County arising from 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 /> i 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:L 4��EO 17.4 Signature: �y7 Date: 9- <br /> Print <br /> Print Name: UDF . !1nJ J-F'We-IV Signature: Date: <br /> Print Name: Signature: Date: <br /> or/ <br /> Print Name; /. /��� Signature: b/- Date: r f S=U <br /> Print Name: Signature: Date: <br /> RZEVSMPlanning Application Forms\Site Approval) Page 5 of 7 <br /> Private Right of Way.(Revised5-11-09 <br /> t <br />