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APPLICATION - SITE APPROVAL <br /> F PRIVATE RIGHT OF WAY - ANTIQUATED SUBDIVISION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: SA- <br /> Other <br /> Describe any items of historical or archaeological interest on-site(e-g.cemeteries or structures): <br /> Cx-!t— <br /> Describe any on-site or off-site sources of noise or vibration e. .freeway noise, heavy equipment, etc. : <br /> O <br /> Describe any on-site or off-site sources of light of glare(e.g.parkinglot lighting,or reflective materials used): <br /> Descnbe any on-site or off-site source of odor(e.g.agricultural wastes): <br /> 'Tl bY1� <br /> Describe any displacement of people that will be caused by the project(e.g. numbers of people, housing units): <br /> L <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 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 /> / In olved in this application, or <br /> ❑ Legal agent(attach proof of the owners 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 /> Date: G <br /> u0PrintName: / rV \CTLIV\d1&&Signature: <br /> Print Named ( \ t (_D`L�1k& <br /> Signature: Date: ICI 12 q0 <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: _ Signature: Date: <br /> F,0EvsvGP1anmrg Applicalon Fom Sde Approval) Page 5 of 7 <br /> Pnvale Right W Way.(Revised4-2d3 <br />