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APPLI CA T100- SITE APP,ROVAL <br /> PRIVATE RIGHT OF WAY-ANTIQUATED SUBDIVISION <br /> SAN JOAQUIN COUNTY COMMUNITY DEVELOPMENT DEPARTMENT <br /> .................___� _ AUTIIORIZAHON VONATURES <br /> ONLY IIIE OWNER Or 1 f IE rnOPER TY OR AN AUTHOR/ZED AGENT MAY FILE AN APPLICATION. <br /> ►, tnr Owner/Agrnt agrro, to defend, Indnrnnlfy, and hold harmless the County and Its agents,offers and employees fbm any claim,action <br /> or proceedhrg against the OwnerlAgent's project. <br /> I, rnrrhrr, certify under penalty of perjury that I am(check one): <br /> o I_rgnl property owner(owner Includes partner,trustee, trustor,or corporate offer)of the pmpedy(s)Involved In this <br /> opplicallon, or <br /> O Lrgal agent(attach proor of the owner's consent to the application of the property's Involved in this application and <br /> have been euthorlred to We on their behalf.,and that the foregoing application statements are Eve and correct. <br /> Print Narne: _t') (2W <br /> ^���i !/� C�' /('S Signature: O �C �— Date: �,��-� .cr4s <br /> -- ,t -- <br /> f'rint Narne: _ Signature: Date: <br /> Pint Name: Signature: Date: <br /> Print Name: Signature: Date: <br /> Print Narnp: Signature: Date: <br /> -5- <br />