Laserfiche WebLink
SAN JOAQUIN COUNTY <br />rusuC BPALTH SERVICES <br />FJ"gR0r4KW rrAL HEALTH DIVISION <br />PURUC RECORD RFXrME APPLICATION <br />APPUCANT PRjONE NO <br />ADDRESS 9 53 ro f fP�Cef r, _� <br />AGENCY NAMH _ l� . v Su 4 PHONE NO S�� <br />ADDRESS S4 rticP . <br />A 17DR&S3 L9ARAQBkDATE <br />S 1 rte, FZ� .3 S- 30 s S <br />S zzz ^�a <br />o CPImckf {�,� 35 <br />�7 M M <br />© L11��/ _r�r-Q'istS l / �fI ,I�r� ,0 5{z�-lin .3J • a- S� (h M <br />0 c i -_T - i f 3 a "1 111xyt <br />TIUS NOTICE IS SUWFiCC TO IM9 REQUIRHMMn H)ENTIFMD IN 7PIP3 PUBLIC HEALTH <br />' FMVICMENVIR(INMHNTALHFALTH DIVIMON (Mt;) POLICY #92-007, ORDINANCE CODE OP SAN <br />.K7AgE1tN COUNTY, FFD f%HS AND SERVICE CHARGE RE.SOLiTTIONS. STATE NATER CODH. <br />UOVIRRN?4ENT CODE AND THg EVII)FNCTI CADS. <br />2. A KAMMUM OF TEN (io) -pREh PSF ADDRESS1ag PAR Ml3E.,`T. <br />2• PUBLIC ML.ESrREC'ORL3 REVIQN ARK BY SRT -'+Ml MLY. APPOINTAt&NI'S Altp <br />ARRANGOD BY CAWNG (20"R-0340. OFPICB HOURS FOR APPOLNTMEN-0 AgE SCHEDULED <br />P40NDAY THRU FRIDAY EKCLUDINO HOLIDAYS, 8:00 A.M. TO 12:00 NOON AND 1:00 PAL TO 4:30 <br />P -ht <br />3. A PUBLIC RECORDS RELEASE APPUCAMON AND A NON4.UjEJ&jVA LE DBFOSIT OF $78.00 <br />IS REQUIRED. DEPOSM WILL BE RH'IIJRNED TO MM APPFICANT IF THIS MZ&TF.CORDS ARE <br />NOT AVAILABLE WITHIN TEE CUSTODY OF THH EFW. <br />�. THE ABOVE IDENTIFIED DEPOSIT IS APPLIED TOWARDS THE TOTAL FILE "VI8W P*EB <br />M- T ARCH. TAE BALANCE OF nM CNARGES ARE DUE AND PAYABLE TO RE IEV4NO THE <br />DOCUME (s). <br />5- MBL[C FR PkS ECORU5 NOT R TURNED 1N THE SAME CONDITION AS REiC&Iv-ED WII.L p <br />CORREC11RD BY 'IIIA MIT) START AT 'IH,E I31CmsEE of THE AP:1ZlC.ANI'.HS3 A,DDPTIOI�AH <br />5FRVIC!? WML"BILUM TO TIM APPLICANT FOR PAYMENT. <br />b. I. <br />CP.IMNAL PUBLIC M-ESIRECORDS SHALL NOT BE REMOVED FROM THE ERD PREMISES. <br />SIGNATURE OF API:LICANT DATEZ (v <br />W-TNATURF OF F.g..RA.. Nlr- ©I:PICIAL DATE <br />PH 00 14 (REV 12f07) <br />TQ?FL F.©2 <br />