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APPLICATION —' site <br />SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br />FILE NUMBER: UP - <br />Other <br />Describe any items of historical or archaeological interest on-site (e.g. cemeteries or structures): <br />NIL <br />Describe any on-site or off-site sources of noise or vibration (e.g. freeway noise, heavy equipment, etc. : <br />NIL <br />Describe any on-site or off-site sources of light of glare (e.g. parkinglot lighting, or reflective materials used): <br />NIL <br />Describe any on-site or off-site source of odor (e.g. agricultural wastes): <br />NIL <br />Describe any displacement of people that will be caused by the project (e.g. numbers of people, housing units): <br />NIL <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 <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 />0 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 />Print Name: S U i<I't C- q A I IJ 61 L(_ Signature: ( C i Date: 2— <br />Print <br />Print Name: Signature: Date: <br />Print Name: Signature: Date: <br />Print Name: Signature: Date: <br />Print Name: Signature: Date: <br />F:IDEVSMPIanning Appiication Forms\Use Permit. (Revised 02-03-10J Page 5 of 9 <br />