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APPLICATION - USE PERMIT <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 of structures): <br />Describe any on-site or off-site sources of noise or vibration (e.g. freeway noise, heaa a qui ment, etc.li <br />Describe aany on-site or off-site sources of ti ht of glare e.g. parkinglot li htin , or reflective materials used): <br />Desc``rib��e an on-site or off-site source of odor (e -g. agricultural wastes)l <br />N <br />Describe any displacement of people that will be caused by the project (e.g. numbers of people, housing units <br />1V+ <br />AUTHORIZATION SIGNATURES <br />ONLY THE OWNER OF THE PROPERTY OR AM 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 />1, 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 M � pCG MSI I�rs R aF ��.Alcur iZ ArI <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: Vd 6—Q f)CL M L°. Signature: Date _I t' 1 <br />Print Name: Signature: Date: <br />Print Name: Signature: Date: _ <br />Print Name: Signature: Date: <br />Print Name: Signature: Date: <br />FADEVSVCi lanning Application FormslUse Permit, (Revised $-03-04) Page 5 of 9 <br />