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APPLICATION -- REVISIONS OF APPROVED ACTION <br /> S <br /> ' X SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> • �d�'iFORt' FILE NUMBER: - 1 <br /> Name: 2` `; M, <br /> Address: t . ��.1 �z' <br /> Address 7� 1 LLGZC1 fit~ �� <br /> Phone CC' ? °tg2 �1CA <br /> 1 <br /> Phone <br /> Pro.... q <br /> $'��9 -:rarer <br /> - t_b,r,c• s .._. . � # .e��. r;s..y�' +' �3�-a�` . �-fi��Asa . <br /> Revision to: Map dition'(s)of Approval <br /> File No: <br /> J <br /> 1. Description of the,proposed Revisions: <br /> S v <br /> 4 62ihCit11 kXA-VO k F'11 t ? ti <br /> Cv.PAA <br /> hid vcZ,2 <br /> S P"o --rL�t LNC ,t AY 4s TIZAM4C-2 e 0;*3i_(-, <br /> Q V1r_ p 1,j 8- 4 _Ot <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER'OF THE PROPERTY OR AN AU <br /> THORIZED_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 Owner/Agent's project- <br /> 1, further,certify under penalty of perjury that I am (check one): <br /> BurLegal 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 foregoing application statements are true and correct. <br /> Print Name: f G &ru w _Pco"aZ) Signature: -_ Date: B—t b -ra tp <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: <br /> FADEVSVOPianning Applicafion FormslRevisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 10-19-04) <br />