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APPLICATION OSITE APPROVAL <br /> PRIVATE RIGHT OF WAY-ANTIQUATED SUBDIVISION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> AUTHORIZATION SIGNATURES <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 employees from any claim,action or <br /> proceeding against the Owner/Agent's project. <br /> 1, further, certify under penalty of perjury that I am(check one): <br /> O 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 application of the property's involved in this application and <br /> have been authorized to file on their behalf.,and that the foregoing application statements are true and correct. <br /> Print Name: POA p y,e__:72 Signature: <br /> 92:2n Date: <br /> Print Name: Signature: / <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> yI'fl':/I'l'IWPIIl AH'1'I!'OIWOIVAPP IIxv.0-9-01 (IIID) <br /> -5_ <br />