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ppQ�rl" APPLICATION �-JSITE APPROVAL <br /> PRIVATE RIGHT OF WAY -- ANTIQUATED.SUBDIVISION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT- <br /> FILE NUMBER: SA- <br /> AN,,S.- 1 ! - <br /> Describe any items•of historical or archaeolo ical interest:on-site e. cemoteries.ar Structures :. <br /> Describe an on-site or off-site sources of noise or vibration e. :freevira noise,hdayy equipment,etc. : <br /> Describe any on-site or off-site sources of light of gLare(e.g. parkinglot lighting,or reflective materials used): <br /> Describe any on-site or oft-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 /> 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 <br /> employees 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 /> V4Legal 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 /> Print Name: �01 D F Signature: Date. 2-'Z,T"02? <br /> Print Name: 4J Signature: Date: <br /> Print Name: Signature: Date- <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F:IDEVSVCIPlanning Application Forms\Site Apprnval) Page 5 of 7 <br /> Private Right of Way.(Revised4-2-03 <br />