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APPLICA v JON - USE PERMIT <br /> a: 1 <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: UP- <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 equipment,etc. : <br /> 4Describean <br /> or off-site sources of light of glare e. parkinglot lighting,or reflective materials used): <br /> Q AJ 65- <br /> or off-site source of odor(e.g. agricultural wastes): <br /> /, t J PIQ p t9� <br /> t V l FV ' L _ T _e <br /> ement of people that will be caused by the pmject(e.g. numbers ofeo le, housin 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 Owner/Agent's project. <br /> I, further, certify under penalty of perjury that I am (check one): <br /> Q 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 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: 1- 95lU !�'i_ -,( &N Signature: Date: �Y 2 <br /> @ )0 <br /> gj <br /> Print Namely i&A)6- AMM k). L f: Signature: Date: i <br /> Print Name: D•d L I LA) F' A2"y FA) Signature: Date:B ! <br /> Print Name. Signature: Date: <br /> Print Name: Signature: Date: <br /> F:IDEVSVC\Plamng Application FormslSite Approval.(Revised 1-3-03) Page 5 of 9 <br />