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Ir__n-lrinn>L _�_ <br /> a S E--P—E—RM <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> FILE NUMBER: UP- - <br /> Other <br /> Describe any items of historical or archaeological interest on-site(e.g.cemeteries or structures): <br /> 140JUL <br /> Describe any on-site or off-site sources of noise or vibration(e.g.freeway noise, heavy equipment, etc. : <br /> w l� <br /> Describe any on-site or off-site sources of light of glare(e.2. parkinglot 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 /> N6,!" <br /> AUTHORIZATION SIGNATURES <br /> PONLYE OWNER OF THE PROPERTY OR AN AUTHORIZED AGENT MAY FILE AN APPLICATION. <br /> er/Agent agree, to defend, indemnify, and hold harmless the County and its agents, officers and <br /> empoyees 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 4 <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 /> GIZECJ.)!1�` C' - `.' . � Date: <br /> Print Name: -®� Signature .y ' <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> SVC\Planning Application Forms\Use Permit.(Revised 1-2-03) Page 5 of 9 <br />