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APPLICATION - SITE APPROVAL <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> : a FILE NUMBER: SA- <br /> FO <br /> Other <br /> Descrba any items of historical or archaeological Interest on-site e. .cemeteries or structures): <br /> None <br /> Describe any on-site or off-site sources of noise or vibration e. .freeway noise heavy egulpment,etc.): <br /> Hwy 99 off site <br /> Describe an v on-site or off-site sources of light of glare e. .parkin2 lot fighting,or reflective-materials used): <br /> None <br /> Descdbe any on-site or off-site source of odor e. .agricultural wastes); <br /> None <br /> Describe any displacement of people that will be caused by-the project e. .numbers of people,housing units): <br /> 2 housing units, neither are occupied or fit for habitation <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 ect. <br /> Print Name: Signature: 1 L Date. 0�-3 <br /> 21DateIrtiuQ�a F2Y2 Signature: :02 <br /> Print Name: - <br /> Print t <br /> Name: Signature: Date: <br /> Print Name: <br /> Signature: Date: <br /> Print Name: Signature: Data: <br /> F:%oEVSVC1P1ann1ng AppficaUon FoWASftMwevei.(Revised 02-oa-10) Page 5 of 9 <br />