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SAN JOAQUIN COUNTY <br /> ' MBLIC IMAL'TI# 5WgCFS <br /> tNV MoNMRN'TAL'AtAL'TH DIVISION 3 <br /> PUBLIC RI;COIWS XtUASI,, AMICA'TION <br /> APPLXANTi"f �i?�"f/1G?c�LIZ _PHONE NO (�lb <br /> \� <br /> ADDIZA85 CSA <br /> AC3BNCY NAME —� PHONE NO <br /> ADDP-PS5 <br /> FILE ADDRESS DA <br /> S <br /> THIS N(rnCH 18 njt& `. ro THE "QtJ=MENTl' IDgN-TIp1ED IN 'illg p'tf13LtC' 11gALTN <br /> sERViCtIs/ENV7ItON IIN'TAL HEALTH btViSloN (MAID) P()I1cY#92�, MWtNANC13 trObE OP SAN <br /> JOAQUIN COUNTY, MID M135 AND sERV10E CHAR08 WOLUll?JNSs "5'1'AI� ,WA'I�It CODE, <br /> GOVBRNMgNT cob AND THE EVIDENCE <br /> 1. A MAXIMUM OF ISN (10) PREMISE ADL).=5ES PER REQUI3S`I. <br /> 7 �11Ut�L]C /It�C0ILb5 ttI3VtE�l ARE 13 �ppOLNiMEN't' tlNLY.' AppOINTMiiNTS ARE <br /> ARRANCIED BY CA Nd (20)468-bj4U, "oprlCE 1-IOURS FOR APPUINTMEN TS ARJ3 SCTtEDUL13 0 <br /> MONDAY'141AU T7R1 AY gXCLUDINO HOLIDAYS, 8!00 A.M. TO 12:tltl NooN AND 1:tltJ I'.tvt� td 4.30 <br /> P,M, <br /> J. A MOUC RE oIWS k131-PAS9 A1IPLICATioN <br /> 4 y •,,1 :. �113f1--t�8I'eg1�--1S--r41 I�--�II3-�'��� ��t�-1�Eg <br /> PulluC F;PtitlC <br /> CORDS NOT 1t�7t M13t)IN'TI�I13 SAME CONDITION AS AECMVED WILL EE <br /> C01tREtMI) gYC( STAPP AT THE EXPENSE UP V8 A PUCANT, TI-II5 ADDITIONALSERVICE WILL 21b `tO THE APPUdANT POP, PAYMENT, <br /> 5. MIGINAtgLtl8ttEC0KI)S s ALL NOT bE PtMOVM PROM 11411 MID PI tMISE5. <br /> SIGNATURE OP APPLICANT ' " bATE <br /> / SIGNATURE OF RELg SIN(J OFFICIAL DATE <br /> EN 00 14 (REV 12/92) <br />