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APPLICATION - MINOR SUBDIVISION <br /> { SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NO: MS- <br /> AUTHORIZATION SIGNATURES <br /> ONLY TF77� HE 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 employees from any claim, <br /> 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,grantor,or corporate officer)of the property(s)involved in this <br /> application,or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and have been <br /> authorized to file on their behalf.,and that the foregoing application statements are true and correct. <br /> Print Name:John E. Blomberg Signature: '/ �// -C-Ak- / Date: <br /> Print Name: Kathleen V. Bennett Signature: Xa. t&wiy %&Wn-f- Date: 0L J'0 S <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> FADEVSVSTlanning Application FonnstMinor Subdivision(Rev.12-09-04) Page 5 of 5 Job No. 2005-259 <br />