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u' APPLICATION - LOT LINE ADJUSTMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> a 'J <br /> FILE NUMBER: <br /> 9�IF ORS- <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 /> I, further, certify under penalty of perjury that I am (check one): <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 /> Triple H Farming, Inc. �( 1 <br /> Print Name: Brenda C. Hausa, Signature: ate: 2 -2.2 - 112_ <br /> President/Secretary <br /> Print Name: Gerald D. Haugg, Signature: Date: Z 2-2- �b <br /> ice President <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:\DEVSMPlanning Application Forms\ Page 3 of 3 Job No 2015-173 LLA <br /> Lot Line AdjustmentAm.(Revised 05-11-09) <br />