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APPLICATION - USE PERMIT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: UP-_- <br /> Describean rchaeological interest on-.ft(e-q.cemeteries or structures) <br /> -y items of historical or a A. <br /> Describe any on-site or off-site sources of noise or vibration(ag.ttEnEy noise,heavy egm- <br /> pment,etc. <br /> OF <br /> H161 WW 70 94!�� <br /> N/ADescribe an on-site or off-site sources of light of lare(e.g.parking lot lighting,ar reflective materials used): <br /> Describe any on-site or qfWde source of odor(e.g.a <br /> gricultural wastes). <br /> D—cdbe any displacement of pe2ple that will be caused by theiect(e.g.numbers of people,hauls unft): <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/Agents project. <br /> 1, further, certify under penalty of perjury that I am (check one): . <br /> 0 Legal property owner(owner includes partner, trustee, trustor, or corporate officer) of the property(s) <br /> involved in this application, or <br /> 0 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: Signature. Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F, 4ame: Signature: Date. <br /> PrintName: Signature: Date: <br />