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APPLICATION - DWELLING CLUSTER <br /> N �, { SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER. DC- <br /> �rFOR <br /> School Service Fire Protection Service <br /> Distance to Elem <br /> Service Provider School Service Provider Distance to Fire Station <br /> U V/ 7d1 ; l L9 W fl-,ch c[ <br /> Existing Roads <br /> Road/Street Name R.O.W.Width Pavement Width Curb/Gutter Sidewalks <br /> 0 Yes 9t No❑ Yes❑ No W]' <br /> Yes❑ No❑ Yes ❑ No❑ <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 /> V <br /> �er, certify under penalty of perjury that I am (check one): <br /> egal 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 stat ments <br /> are true and correct. � ���✓� <br /> Print Name:�/r ?84 7,!1 IM 'Date: 4 G ,2 <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 Page 4 of 6 <br /> Dwelling Cluster(Revised 5-11-09) <br />