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5A- 9(o-y'
<br /> APPLICATION - REVISIONS OF APPROVED ACTIONS
<br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT
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<br /> Name: l.V u r �c ` t� l Name:
<br /> Address: 3012- Wv QCT Address: � '2'� 1 ��S �C YG
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<br /> Phone: 20 CI - 4 G 6 Phone: --,o Cl — LI-7 L( _3 � /
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<br /> Revision to: Mao Condition/s of Approval
<br /> File No: l 14'3 -)4 0 3
<br /> 1. Description of proposed Revisions:
<br /> 01,2-D_ +\AA -VN\.A Inn Y LAC_ S 04_A.A� ct 1 ` SYS
<br /> 2. State the facts showing the changes in circumstances which make the subject condition(s)no longer aro riate or necessary.
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<br /> AUTHORIZATION SIGNATURES
<br /> ONLY THE.OVMER OF THE.PROPER-T.Y.-:ORAN.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 /> Legal property owner(owner includes partner, trustee,trustor, or corporate officer) of the
<br /> I property(s) involved in this application,or
<br /> i
<br /> j ❑ 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: C kA ( ��G( S fGt taw' Signature: !G Date:
<br /> Print Name: Signature: Date:
<br /> Print Name: Signature: Date:
<br /> Print Name: Signature: Date:
<br /> Print Name: Signature: Date:
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