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J <br /> 3 08PH F i~ AGE NU "ZU'J <br /> SAN JOAQUIN COUNI'y <br /> PUBLIC I�EAH. 'Hi <br /> • 7SERVICES <br /> FN ,:.MONMENTAL IYCA.LTH MVISiON <br /> >f'UiiL1C tCC0111)S ltl%i,KASE APPLICATION <br /> 1 <br /> A1�Y1.Ic'APTF T r_ - �a__G�� <br /> f ny�_ (SEPI 10NE N� �Q - -- <br /> ADDRESS t$ o LA �-1H <br /> AGENCY NAMH Plri[�Nlf3 NO <br /> ADDRESS <br /> r C) D LAT� <br /> kk <br /> r <br /> �s.�Z2� <br /> ..^ — <br /> Tilts NUTICI'a IS SL)l1JirCT l'Q -i'{lE, RCC?Utit>rh'!1'hCE:sMi[�i':N"f7!•llvi� IN '111~ f'i3ftLit� 19FALTf-i � <br /> SF -HGAL'lyl DIVISION (V11D)!'()l,IC #92 i�7.hRDt1+lANCEC©DE Dt SAN i <br /> JOAQUIN CdUN-I'V. Flit) FEES AND SERVL('V CHARGE RESQi_UIIONS, STATE WA'lT� C13T31?, <br /> CiOYEFtNM1iMi CUU[3 AND THi3 EVI1]F-Ncja CODE. <br /> 1 A MAXIMUMUt?TEN (lo)PREMISE Ar DRESSES PER ttEQUGSST. <br /> 2- plitit 1[' F!i_FfilitECOF.!7S RFVt[IW ARF TIY A1'Pf11NTM1;l1-P., ARE <br /> RRRhN(7k17 BY C'AWNG (20:$)4b8(il;U. AFFlCR 1lbURS FOR APPOIN7VI-tNI'S ARE SCHEDULED <br /> hI()NUAY nI1tU VIUDAY EEC UJDINO I;O1,IDAYS, S:UO A.M. '1'O 12:00 NO[ N AND I:DO P.M.TO�F; 4 <br /> F.M. . <br /> 9, w PUI3Uc Ri r_�c)1tUS R>"1,FASl: A1,111-ICA-110N AND A�1U�L=KGir1� ) It DEPOSIT Or$78.40 <br /> iS IlEQU1R VB DEPOSITS Wtii BLS RE "l() TJIE APP11CANT :F T1tt_ FILESIRI;CORDS ARE <br /> NOT AVATLA"WITHINTIIH CV5f4DY OF TH1?Yo110. <br /> LE REVIEN1 FRE <br /> 4. I7rlE ABOVE LE7EN TI�F;E ) DEPOSIT ARIE IMUS Atli?PAYABLE APPLIED I'0WARDS111E Tll'1Uk)R TO1REVIEW1146 THE <br /> t"BARGE. Tilt~ HA LANCE U. t71h CHARL. <br /> ES <br /> S. PUlstlC T Ii ESlIiF;�C)P.uS h1l7TRER$FiN1=[Z il+l'ili SAM1':COND1110N AS RECEIVED I/1LLbe <br /> C)RKECiFD $Y 7 113 KID STAFF AT 'IME EKPENSR OP I?1E AFpUCANT. <br /> (. THIS ADDT I ONAL i <br /> C R RUC W111.RF. itll_1-F.T)To 111E APt'UCAN'C FOR PAYMENT. 1 <br /> G. ORIGlI`IAL 1?UI31�C IrIL S/IIECd13I)S SHALL NUT BE REMOVFD FROM THE EHD T'RE.MISI:S. <br /> - - DATE _. <br /> SIGNA'IUR.13 OF �1p1'LJCANT <br /> r <br /> pATE _ <br /> SI[3NA'i'UKL'()F REI:EA ING OFFICIAL —------ <br /> (K) 14 {RFV 12192) <br />