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APPLICATION - USE PERMIT <br /> { SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> PILE NUMBER: UP- <br /> Other <br /> Describe an items of historical or archaeolo ical interest on-site(re.g.cemeteries or structures : <br /> Describe an on-site or off-site sources of noise or vibration(e.g.fre <br /> ewa noise, heavy equipment,etc. <br /> Describe an on-site or off-site sources of li htof glare e. _parking lot li htin , or reflective materials used <br /> Describe an on-site or off-site source of odor(U.agricultural wastes): <br /> Describe anv dis lacement of Peo le that will be caused by the ro"ect e. . numbers of eo le,housin units <br /> AUTHORIZATION NATURES �.. <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 County arising from the Owner/Agent's project. <br /> 1, 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 /> s <br /> involved in this application, or y( ) <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 /> Print Name: ems.- .�� Signature: -� <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> FIDFVSV0PIanning App3ication FormsSuse Permit.(Revised 02-03-10) Page 5 of 9 <br />