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oRUN APPLICATION — LOT LINE ADJUSTMENT <br /> ?< SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> c . P FILE NUMBER: <br /> a�fioR�i� <br /> % <br /> _Ril; n�,� �� AUTIRiZATt11G1± 4t� :E . . . a . ' <br /> ..tt„„'w .+@` is ' ^5"4'� f t'�k'€z i's'° s✓i ,tiY .- 'sa;?3uIq`, x <br /> E <br /> ".t � 'a^' <br /> t3N. E bWNER Ql= "H AN1UTHCRI ( 3 CIEhI f . a► (,FIL .�41V AP'IPLIGAt1 <br /> E <br /> 1, 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 /> ® 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 /> APN 201-150-09,10,17,18 AND 19:Van Groningen&Sons,Inc. <br /> Print Name: Dan Van Groningen Signatur Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:IDEVSMPIanning Application Forms\ Page 3 of 3 Job No 2011-124 LLA 2.doc <br /> Lot Line Adjustment.doc.(Revised 6-4-04) <br />