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APPLICATION - USE PERMIT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> • 4 � FiLE NUMBEk. ..UP-; <br /> r . ' .s��s� �� 'uLx'p��3 �ss�" T� 3�!'eYi "'` Y' ''Y• ,{�'�`�'P +"7'�'�`,�° '� i w:"v ..I �.,�. <br /> Describe an items of:histoncal or erchaealo Ical m#erest on-site e :cemetenes.o5tructures Q <br /> t C <br /> - t <br /> :l <br /> Describe an .6n-site or off-site sources f:noise or,vibration e. .,freewa ::noise, heavy e ui ment.etc. . <br /> Describe any on-site or off-site sources of light of glare e. .parking lot lighting,or reflective materials used): <br /> Describe any on-site or off-site source of.odor(e.g.a ricultural wastes)- <br /> Describe <br /> astes :Describe any dis lacement of people that will be caused by the project(e.g.numbers of people,housing units): <br /> AUTHORIZATION:,$IGNAWRES <br /> ONLY.TFIE OWNER OF THE.PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION: <br /> i 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 /> a V - <br /> Legal property owner(owner includes partner, trustee, trustor, or corporate officer) of the property(s) <br /> Involved in this application, or <br /> ❑ <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: r Signature: Date: <br /> Print Name: ��� Signature: - Date: l/ ®2. <br /> Print Name: Signature: Date: <br /> Print Name: " - Signature: Date: <br /> Print Name: Signature: Date: <br /> F:IDEVSMPlanning Application Forms\Use Permit.(Revised 1-2-03) Page 5 of 9 <br /> h <br />