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F I` AGE NC 209 956 0700 P. 1 <br /> ri0 <br /> SAN J AQUIN COUNTY <br /> T PUBLIC xEAL•rH sKRvICFs (/t(L( - y <br /> ENVIRONMENTAL HEALTH DIVISION <br /> IIS IC RECORDS RELEASE APPLICATION <br /> APPLICANT niUa G- r +aj — :L=C It'IrpHON-H NO a5 s, a 2 k'f <br /> ADDRESS_LU;3_ <br /> AGENCY NAME �I'HONE NO <br /> ADDRESS <br /> FILE ADDRASS i PAD AGENCY. DATE <br /> -7hn � Ind sir'wl �r C <br /> SFrC + <br /> QBE <br /> - 101-1 E . <br /> 4A L?— S fl n naa ---__-- <br /> -nils NOTICP- IS SUBJECT TO THE REQUIREMENTS IDENTIFIED IN 174E PUBLIC HEALTH <br /> SERVICESIENVIRONMENTAL HEALTH DIVISION(EHD)P013CY#'92-007. ORDINANCE CODE OF SAN <br /> JOAQULT' RESOLUTIONS, STATE WATER CODE. <br /> GOVI3RN <br /> JenPERREQUESI'. <br /> 2. p /'`I/��-" `.-`Cl�r� �,� 7_yf _TMENT ONLY. APPOINTMENTS ARE <br /> ARRANC 1. S FOR APPOINTMENTS ARE SCHEDULED <br /> MONDA' M. TO 12:00 NOON AND 1:00 P.M. TO 4:30 <br /> P.M. reciu-eat <br /> 3. e J 1 1�C � I A NON-REFUNDABLE DEPOSIT OFS78.00 <br /> IS REQU; + _ J G, APPLICANT IF THE p1LESlKIiCORDS ARE <br /> NOT AVi I/IZ # J-�-� J <br /> 4 7 'OWARDS THE TOI'Al, FILE REVIEW FEE <br /> CHARGE ND PAYABLE PIUOR TO REVIEWING THE <br /> DOCUMI <br /> '� 1 �Cl� <br /> 5. p t`, SAME CONDITION AS RECEIVED WILL BE <br /> CORREC IF THE APPLICANT. THIS ADDITIONAL <br /> SERVICE WILL BE BILLED TO nIE APPLICANT FOR PAYMENT. <br /> 6. ORIGINAL PUBLIC FILFS/RECORDS SHALL NOT BE REMOVED FROM THE E14D PREMISES. <br /> SIGNATURE OF APPUCWT G" It, DATE 3 9 <br /> SIGNATURE OF RELEASING OFFICIAL. DATE <br /> 191 00 14 (REV 12/92) <br />