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APPLICATIDN - SITE APPROVAL <br /> ^'I SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> '•s"' °- "-,� FILE NUMBER: SA- <br /> Other <br /> Describe any items of historical or archaeological interest on-site(e.g.cemeteries or structures): _ <br /> Describe any onsite or off-site sources of noise or vibration(e. .freeway noise,heavy equipment,etc.): <br /> 1_V lJV <br /> Describe anv cnshe or off-site sources of G e of g1we fe,q, rkinq lar Wing,or reflective materials used): <br /> � r <br /> Describe my on-site or off-site source of odor [e.agricultural wastes): <br /> Describe env displacement of people that will be caused by the project e. .numbers of peorla,housing units): <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <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 County arising from the Owner/Agent's project. <br /> 1,further,certify under penalty of perjury that I am(check one): <br /> i <br /> Legal property owner(owner includes partner,trustee,trustor, or corporate officer)of the property(s) i <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: &7LJ� ;n2,A, � Signature: <br /> Print Name: Signature: / ' Dale:, . <br /> Print Name: - Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: _ Signature: Date: _ <br /> I <br /> rwE SVC1 Iennlne AppEcotlon ronnsWe Approval.(n<Yised 02-03-10) Page 6 of 9 <br />