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P�� ,N APPLICATIO`II -- USE PERMIT <br /> �. <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: UP- <br /> Other <br /> Describe any items of historical or archaeolo ical interest on-site(e.g. cemeteries or structures <br /> KA p "c—� <br /> Describe any on-site or off-site sources of noise or vibration te.g. freeway noise, heavy equipment, etc.): <br /> Describe any on-site or off-site sources of li ht of glare(e.g. parkinglot lighting, or reflective materials used): <br /> Describe any on-site or off-site source of odor(e.g. agricultural wastes): <br /> Describe any displacement of people that wilt be caused by the ro'ect e. . numbers of people, 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 Owner/Agent's project. <br /> 1, further, certify under penalty of perjury that I am (check one): <br /> V1 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 /> Print Name: ' tu �� t C :c r_� Signa#ure: '�^�- ! 1 iG --Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F+DEVSVC`Planning Application Forms%Use Permit (Revised 1-2-03) Page 5 of 9 <br />