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U..1. APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> >.• ,RCL'.CSG <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> nA <br /> qC I is o.�ii <br /> �P FILE NUMBER: <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: DSS Company dba Knife River Construction Name: Same as Owner <br /> Address: P.O.Box 6099 Address: <br /> Stockton,CA 95206 <br /> Phone: 209-948-0302 Phone: <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to:Quarry Excavation Application Map Condition(s)of Approval PA-050084 <br /> File No: <br /> 1. Description of the proposed Revisions: See Attached <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> See Attached <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 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, 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 th roperty's involved in this application and <br /> have been authorized to file on their behalf., and that the foreg ion statements are true and correct. ) <br /> Print Name: Steve soya„ Signature: Date: <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 Forms\Revisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 05-11-09) <br />