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1 . �A <br />J <br />APPLICATION - MINOR SUBDIVISION <br />SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br />FILE NO: MS - <br />'q; . _ <br />AUTHORIZATlO`,N' SIGNAL ORES <br />ra- <br />- <br />ONLY THE OWNER OF THE PRQPERTY OR AN Al1THOR'IZED AGENT MAY FjLE'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 />APN 245-160-31 <br />Arthur Van Groningen, Successor Trustee of the Arthur Van Groningen and Wilna Van Groningen By Pass Trust, U/A/D 7/23/91, <br />as amended <br />Print Name: Arthur Van Groningen, _ Signature:, ,roz:' -�.— Date: <br />Successor Trustee <br />Arthur Van Groningen, Trustee of the Arthur Van Groningen and Wilna Van Groningen Survivor's Trust, UTAID 7123/91, as <br />amended <br />Print Name: Arthur <br />an Groningen, Signature <br />Trustee <br />^ Date: r <br />Arthur Van Groningen, Successor Trustee of the Arthur Van Groningen and Wilna Van Groningen Marital Trust, U/A/D 7/23/91, <br />as amended <br />y <br />Print Name: Arthur Van Groningen, <br />Successor Trustee — {j <br />F \DFVSVS\Planning Application Forms\Minor Subdivision (Rev 12-09-04) Page 5 of 5 2010-34 MS.doc <br />