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g A <br /> °p4uIN APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> A SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: - <br /> TO BE COMPLETED BY THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> Owner Information Applicant Information <br /> Name: /ADL ; /S Name: l^OLU l S <br /> Address: A/1E5/ 6C"X16CCe LC,ol� Address: <br /> Phone: <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: Map Conditions)of Approval <br /> File No: "fi - , <br /> 1. Description of the proposed Revisions: p /- vie <br /> -,19 676-M s -- - e AloaOs <br /> 'W_A_;0 r 7 / c 7;1/Z-z)y 1 CX)O S F'i GL >E 4"/7/- <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <br /> G'O Pz v,r� O - ?nom ez-cJ 11-Cr `'�iit/d /•old/-�i <br /> -a,e /77"7 s Sjo� L` .t/O <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 employees <br /> from any claim, action or proceeding against the Owner/Agent's project. <br /> I, further, certify under penalty of perjury that I am (check one): <br /> 1211"Legal property owner(owner includes partner, trustee, grantor, or corporate officer) of the property(s) involved in <br /> this application, or <br /> ❑ Legal agent(attach proof of the owner's consent to the application of the property's involved in this application and <br /> have been authorized to file on their behalf., and that the foregoing lication statements are true and correct. <br /> it/E / 1/ -3•-3c) <br /> Print Name: �% / Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:\DEVSVC\Planning Application Forms\Revisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 10-19-04) <br />