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APPLICATION - REVISIONS OF APPROVED ACTIONS <br /> ).+�E•..off <br /> �E :< SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: !A n O�7 4- <br /> GrFpRH aY- <br /> TORE COMPLETED By THE APPLICANT PRIOR TO FILING THE APPLICATION <br /> O"rinformation ApplicantIrtfotmatiort <br /> Name: Liar- Ccn ``'-{' .e, Name: V7 k- Se. <br /> Address: 10Z) QE —) d Q' Address: 0-0 <br /> cs=;� o ara <br /> Phone: 16� 9- S ( ) 5-gy3 Phone: w b - g <br /> PROJECT DESCRIPTION <br /> Proposal <br /> Revision to: Map Condition(s)of Approval <br /> File No: <br /> 1. Description of the proposed Revisions: e- - SC e Ce or W e y <br /> C La- UCQ <br /> 2 ) 0 <br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer appropriate or necessary. <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 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, 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 for oin a Iic statements are true and correct. <br /> Print Name: ce- Signature:, : / i Date3-1/-/q <br /> Print NameSignature: C Date:�-I <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> ROEVUCTIanning Application Forms\Revisions of Approved Actions.doc Page 2 of 2 <br /> (Revised 05-11-09) <br />