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APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> < SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> �dtp FILE NUMBER: - <br /> foA _rW-W 7-x-- 4 4-. <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION VV �_ <br /> Owner Informati n Applicant Information <br /> Name: -Z <br /> 11 r� 'Co ! Gv= Name: rj <br /> Address: ZHI �j C Address: �Q <br /> Phone: — 9 — 9 Z Phone: —7 <br /> _7_r CO >i+/ PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: Map Condition(s) of Approval <br /> File No: <br /> 1. Description of the proposed Rewsions: <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> Pao <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 employees <br /> 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, grantor, or corporate officer)of the property(s) involved in <br /> this application, or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and <br /> have been authorized to file on.their behalf., and that the fsI application state is are true and correct. <br /> Print Name: SSignature: Date — <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signa Date: <br /> F TEVSVCT[anning Application FormslRevisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 05.11.09) <br />