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t <br /> s <br /> APPLICATION - SITE APPROVAL <br /> PRIVATE RIGHT OF WAY - ANTIQUATED SUBDIVISION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> C%PORN\ <br /> FILE HUMBER: SA- <br /> Other <br /> Describe any items of historical or archaeological interest on-site e. .cemeteries or structures): <br /> 0 <br /> Describe any on-site or off-site sources of noise or vibration e. .freeway noise, heavy a ui ment,etc.): <br /> t<L <br /> Describe any on-site or off-site sources of light of glare e. .parking lot lighting,or reFle.tive materials used): <br /> (OLL IF <br /> Describe any on-site or off-site source of odor e. .agricultural wastes): <br /> CIAO W-(- <br /> Describean dis lacement of people that will be caused by the project e. .numbers o people, housing units): <br /> AUTHORIZATION SIGNATUPES <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 tha 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 /> ❑ 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 cf 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 /> 0 1� <br /> Print Name: C'G- �d�'//`�+tJ Signature: Date: Z/ <br /> Print Na Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> F 0EVSVCWlanning Application Foro s\Sita Approval) Page 5 of 7 <br /> Private Right of Way.(Revise4-2-03 <br />