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>.. .o� APPLICATION '— TE APPROVAL <br /> PRIVATE RIGHT 4'F WAY -- ANTIQUATED SUBDIVISION <br /> •' SAN_JOAQ.UIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> �dtrt oa�'�a FIVE',NUMBER: SA- <br /> 77 <br /> - s � o-} rk <br /> i x t r f A -r F ut}sae j }., <br /> i Describe an items of historical or archaeola ical interest ori=site e. :.cenietenes or structures <br /> r ,I' '_ <br /> . Describe an an=site:or aff-site sources of;noise or yil ration e; freewa .'noise hea. : a ul .ment etc . <br /> I <br /> AJ <br /> + " <br /> Describe any on-site or off-site sources of li hit of lane(e;-. arkin :lot lighting,or reflective materials.used)-. <br /> r/V`� <br /> Describe an on-site or`off-site source of odor.(e.q.agricultural wastes): <br /> Ai <br /> Describe an! dis kacement of eo le that will be caused b the ro'ect(e.g.numbers of peo2le,housing units): <br /> { <br /> AUTHO:IZIZATIQN SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AG.ENT.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 Owner/Agent's project. <br /> , i <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 /> in this application,Pplication, 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 /> l <br /> Date: ./"6 - <br /> Print Name: _�� A)t4 �2I��tZlS Signature: t <br /> Print Name: <br /> M 1 n'I i� ! s Signature Dake: <br /> Print Name: /'" <br /> Ur Signature: Date: <br /> ' <br /> Signature: Date: <br /> Print Name: <br /> Print Name: <br /> Signature: Date: <br /> 1DEVSVCV'ianning Application Forms\Site Approval) Page 5 of 7 <br /> i. <br /> -ivate Right of Way.(Revised4-2-03 I <br />