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APPLICATION -- SITE APPROVAL <br /> rn:• � F '�Y y-C <br /> - ANTIQUATED SUBDIVISION <br /> PRIVATE RIGHT OF WAY <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> Ci••. �P <br /> FILE NUMBER: SA- <br /> Other <br /> Describe any items of historical or archaeological interest on-site(e.g.cemeteries or structures): <br /> I/4N1� <br /> Describe any on-site or off-site sources of noise or vibration (e.g.freeway noise, heavy equipment,etc. : <br /> Alo <br /> Describe any on-site or off-site sources of light of glare (e.g. parkinglot lighting,or reflective materials used): <br /> MIME <br /> Describe any on-site or off-site source of odor(e.g.agricultural wastes): <br /> c�/v <br /> Describe any displacement of people that will be caused by the project(e.g. numbers of people, housing units): <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 /> 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:/vWS d/J A Signature: Date: (j c/�'2 Z <br /> Print Name:,JLI tint � Signature: �. Date: t I <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:\DEVSVC\PlanningApplication Forms\Site Approval) Page 5 of 7 <br /> Private Right of Way.(Revised5-11-09 <br />