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pu APPLICATIC/A - USE PERMIT <br /> N SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> l <br /> l ... FILE NUMBER: UP- <br /> 9'..... <br /> �/FOPN <br /> Other <br /> Describe any items of historical or archae6o ical interest on-site(e.g. cemeteries or structures): ' <br /> Describe any on-site or off-site sources of noise or vibration e. .freeway noise, heavy ui ment, etc. : i 1 <br /> s' <br /> Describe any on-site or off-site sources of light of glare (e.g. parkinglot lighting, or reflective materias used): <br /> Describe any on-site or off-site source of odor(e.g. agricultural wastes): /�i - <br /> Describe an displacement of Deo le that will be caused by the project(e.g. numbers of people, housing units): <br /> i <br /> I <br /> AUTHORIZATION SIGNATURES <br /> ONLY THE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> I, 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 /> E, 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 forecoing application statements <br /> are true and correct. <br /> Print Name: Signature: , " " - Date: <br /> Print Name: ril`� ✓ /- Signature: u���':?li ����..f_� Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Dale: <br /> F.OEVSVC'Planning Appl�Wn FormslGse Permit. (Revised 1-2-03) Page 5 of 9 <br />