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SAN JOAQUM COUNTY <br /> PUBLIC HEALTH SERVICE-S <br /> ENVIRONM]ENTAL IIFA.LTH D VISION <br /> PUBLIC` R-EcoRiDS IzKr.1I:.ASE APPLICATION <br /> ADDRESS <br /> AGENCY NAMM PHONE NO <br /> ADDRESS _ -- <br /> TILS ADDRaSS LEA <br /> 6 �+r _ <br /> . <br /> �5 �3 I <br /> W ter- � .��' ��• _ �_�''� <br /> 4A �c <br /> 77it5 NUT[Ci: f3 SUI3JI~Ci' 'f0 TINE <br /> RF -)44IiNTS iUE.h7'TII-IE7?^iN '11iI PUBLIC HEALTH <br /> 5E ttVl[.t SIEN VIRdItA3EN t"A l.t;?rAI�Tt� DIV1S10N(Ftif)) POLICY#92-007,0RC}iN,�fV{:E ConE of SAf`i <br /> IOAQUIN COi.M-Y, E11D FEES AND SERVICE CHARGE RESCZI...IJ"BONS, STATE WATER C0D.C., <br /> OOVEcRNM1ENT CODS AND TK.9 BViDENCB CODE. <br /> E. A MAxIIv um OT+TEN {10} pREmisrs ADDRESSES PER REQUEST. <br /> . plii�Iat' FILF;SM020RDS REVEI'W ARF SY Al-juNim hLT-nN1,Y. APPOINTMENTS ARE <br /> ARRANGTED BY CALI.3NG (209)469-X0340. OFFICE HOLIRS FOR APP()Iti3'h1EI�17"S ARL SCiiI:I.}UL-D <br /> MONDAY 114RU FRIDAY ILXCLUDIN(7 1IU.i.I0AYS, 8:W A.M- 'TO 1100 NOON AND 1,00 P.M.TO 4.30 <br /> P.m. <br /> 3. , A 13UBLIC FLECORDS RELEASE A[aPUCATION AND A y(3N-FLE,U- QA0I.f: I)i:f'OS!'f of'S79-00 <br /> IS REQUIRED. DEPOSIT'S WILL ISL RETURNED T'4? TIM APPLICANT IF 7iIL FILIrSfRECoKDs Am.. <br /> NOT AVAILABLE WITHIN T14H CUSTODY 0V 714E Irtif3. <br /> 4. TAG ABOVE tI)I NT'iFISD DEPOSIT IS APPLIED TOWARDS f-I E TOTAL FILL? REVIEW FEE . <br /> CHARGE. 'mR HAL NO3 OF THE CHARGES ARE DUE ANI) PAYABLE F'iti(lR TO REVIEWING THE <br /> DOCUMENT(S). <br /> S. PUBLIC RLESIRECORDS NUr RETURNED•II+ THE SAmr-CONDITION AS RECEIVED WILL RF <br /> CORRECTEi) BY THE HHD STAFF AT THE EXPENSE OF THE APPLICANT. THIS A <br /> DDi'1'IONAL <br /> SERVICE WILL BE BILLED TO THE APPLICANT FOR PAYMENT. <br /> 6. DEUCINAL.PUFL_EC FIL>SJAECORDS SHALL NOT BE REMOVED FROM THE F..HD PREMISES. <br /> SIGNATURE OF APPLICANT DATE � <br /> SIGN'ATL RH Of RELBAS1NG OFFICIAL rJA'r� <br /> QI 00 14 (REV 12!92) <br /> I -d 8Ll l 'Z-9V 6OZ WNOZ:lIAN:D0:30 (130Nt1AOV WOd=i NVOS: 11 8561-80-5 <br />