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x:°A�ut" PLAN MAP AMENDMENT <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: - <br /> 4�IjdORN <br /> �,�� - •;� § �' ` .max rswz a.:- <br /> Describe an` hazardous mataalslwastes that wdl be res`"_r t on-site <br /> 4� t } <br /> �.i _,�, �.:'`�n "xr n ay.:,;�t F; ` n;�•'; �� :.i .�.r.. � � �S�t r� � �. ,??i'`r,�-- ,!� �h v �sX• <br /> Describe any items of historical or archaeological interest on-site(e.g.cemeteries or structures): <br /> Describe any on-site or off-site sources of noise or vibration (e.g.freeway noise,heavy equipment,etc.): <br /> Describe any on-site or off-site sources of light of glare(e.g.parking lot lighting,or reflective materials used): <br /> Describe any on-site or off-site source of odor(e.g.agricultural wastes): <br /> Describe any displacement of people that will be caused by the project(e.g.numbers of people,housing units): <br /> AUTHoRQATION 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 /> W"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 agplicationAatements are true and correct. <br /> Print Name: � 1 /'U Signature: Date: AD —/J-0X/ <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\ Page 7 of 7 <br /> Plan Application Amendment.doc.(Revised"3-04) <br />