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APPLICATION ITE APPROVAL <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> rt.. FILE NUMBER: SA- <br /> Other <br /> Describe any items of historical or archaeological interest on-site(e.g.cemeteries or structures). <br /> Describe any on-site or off-site sources of noise or vibration (e.g.freeway noise, heavy a ui ment, etc.): <br /> Describe any on-site or off-site sources of light of glare(e.g.parkinglot lighting, or reflective materials used)- <br /> Describe <br /> sed :Describe any on-site or off-site source of odor e. .agricultural wastes): <br /> Describe any displacement of people that will be caused by the ro'ect e. . 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 th a lication of the property's involved in this <br /> application and have been authorized to file on their h f., and that the foregoing application statements <br /> are true and correct. o <br /> Print Name: r Signature Date: [r -lam <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:\DEVSVC1Planning Application Forms0te Approval.(Revised 05-11-09) Page 5 of 9 <br />