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APPLICATIt-rN - USE PERMIT <br /> y. 4�1 SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> { <br /> PILE NUMBER: UP- <br /> \L_7 <br /> �T Other <br /> Describe_any items of historical or archaeological interest on-site(e.g.cemeteries or structures): <br /> I <br /> Describe any on-site or off-site sources of noise or vibration (e.g. freeway noise, heavy equipment, etc. : <br /> Describe an on-site or off-site sources of light of glare (e.g. parkinglot li htin , or reflective materials used): <br /> E <br /> Describe an on-site or off site source of odor e. . a ricultural wastes <br /> 1 <br /> Describe any displacement of people that will be caused b the ro ect e. . numbers of eo le, housin units <br /> IL <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 County arising from the Owner/Agent's project. <br /> 3 <br /> I I, 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) <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 /> I ��L t lc � - <br /> Print Name: r r�,# �C Signature: Date:/ <br /> Print Name Signature. - Date <br /> Print Name: Signature: _ Date- <br /> Print Name: _ __— -_-___ __ Signature: _ Date: <br /> [ Print Narne: — _ _ Signature: -_— -- —_ Date: <br /> F%DEVSVCiPlanning Application Formsluse Permit (Revised 05-11-09) Page 5 of 9 <br />