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,�ourN <br /> ( ,. .� APPLICATION -- USE PERMIT <br /> '�.• ��rri •�11 <br /> .. SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> <rr � FILE NUMBER: UP- <br /> Other <br /> Describe an items of historical or archaeological interest on-site(e.g. cemeteries or structures): <br /> U � <br /> Describe an on-site or off-site sources of noise or vibration(e.g.freeway noise,heavy equipment,etc. : <br /> Interstate 5(Approximaleh 700' rrotn site) <br /> Descr`1 hibe an on-site or off-site sources of light of glare e.q- parkino lot li htin , or reflective materials used): <br /> ra <br /> u <br /> Ore r' <br /> C1f�r of <br /> Describe an on-site or off-site source of odor e. .agricultural wastes <br /> 2. <br /> t I /C W k t <br /> Describe an dis lacement of eo le that will be caused by the project re. .numbers of people,housing units): <br /> NdK <br /> AUTHORIZATION SIGNATi�r�Fc — —1 <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 <br /> ne):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 correct. <br /> '7.ra1: L-Lx— --o .. – <br /> Print Name: Signature: O .- <br /> ✓ Hate: <br /> Print Name: Signature: <br /> Print Name: Signature: <br /> Date:--- <br /> Print <br /> ate: __Print Name: Signature <br /> Date: <br /> Print Name: Signature: <br /> Date: <br /> F:IDEVSVCIPlanningApplication FormsWse Permit.(Revised 02-03-10) Page 5 of 9 <br />