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S A - 01 - 30
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<br /> APPLICATION - REVISIONS OF APPROVoED ADCTRONS
<br /> SAN JOAQUIN COUNTY COMMUNITY
<br /> .................... .... TMENT
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<br /> Name: S i one K . Ha f oka Na-
<br /> Address- 4331 Cherokee-R Address:
<br /> Stockton Ca 95215
<br /> Phone: 20 9-9 31-4732 Phone:
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<br /> Revision to: Map Conditionds of Approval
<br /> File No: of Approval SA-01 -30 ---
<br /> 1. Descri tlon of proposed Revision%:
<br /> 1C - I w o
<br /> Of
<br /> 1�i v dairy of t h e rev'
<br /> 2. state the facts showing the chap es In circumstances which make the subject conditions no longer aro riate or necessary,
<br /> T
<br /> flood zone 35 feet elevation ,
<br /> Hauling of dirt
<br /> Reenclinger of dr
<br /> C �truction of the n w b
<br /> of aDnroval .
<br /> :..AUTHQRiZATION SIGNATURES
<br /> s..:::¢:::•:.::..:. ::.
<br /> ONLY YH>=OWNER O 'FH�,P..ROP 14TYOR AN.AUT�IORI D.AGENT MAY:F..iLE AN;:APPLICA'L10N ....::':
<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 /> 1,further, certify under penalty of perjury that I am(check one):
<br /> XD Legal property owner(owner Includes partner,trustee,trustor,or corporate officer)of the
<br /> property(s)involved in this application,or
<br /> 0 Legal agent(attach proof of the owner's consent to the application of the property's
<br /> involved In this application and have been authorized to file on their behalf.,and that the
<br /> foregoing application statements are true and correct
<br /> � I
<br /> Print Name: _Slone K Ha ka Signature: -•- "' '
<br /> .,:ate:
<br /> Print Name: __.. .
<br /> Print Name•
<br /> Signature*. - Date:
<br /> Print Name'
<br /> Signature: Date:
<br /> Print Name: --
<br /> Signature: Date:
<br /> -2-
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