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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> • ' MASTER FILE RECORD INFORMATION FORM -PUBLIC WATER SYSTEM <br /> ® New Public Water System at Existing Facility ❑ New Public Water System and New Facility <br /> Facility ID FA0021951 Program Record ID PR Z75 I_ rl <br /> Facility Address 4642 Mosher Dr <br /> (Please check the appropriate description and specify size, number of units and pertinent information) <br /> PUBLIC WATER SYSTEM PROGRAM 4600 <br /> APPLICATION <br /> ❑ New Small Community Water System(SCWS) (4603) Dates of operation to <br /> ❑ New Non-Community Water System (NCWS) (4602) Dates of operation to <br /> ❑ Permit Amendment(4604) <br /> PERMIT <br /> ❑ State Small Water System (4644) 5-14 Service Connections <br /> ❑ SCWS (4521) 15-24 Service Connections <br /> ❑ SCWS(4622)25-99 Service Connections <br /> ❑ SCWS (4623) 100-199 Service Connections <br /> ❑ Non-Transient NCWS (4630)Serving the same 25 or more individuals=>180 days per year <br /> ❑Transient NCWS(4633)=>25 Customers/Consumers per day <br /> ❑ Surface Water System(SCWS) (4670) 15-199 Service Connections <br /> ❑ Surface Water System (NCWS)(4671)=>25 Consumers=>60 days per year <br /> ® CURFFL NCWS (4616)—Food Facility without Water/ice service for customers <br /> Type of Water System Service Area <br /> ❑ Residential Area (R1) ❑ Day Care Center(S5) ❑ Hotel/Motel (T6) <br /> ❑ Mobile Home Park(R2) ❑ Other Semi-Residential (S9) ❑ Other Transient Area(T9) <br /> ❑ Other Residential Area(R9) ❑ Recreation Area (T1) ❑ Interstate Carrier(01) <br /> ❑ School (S1) ❑ Service Station(T2) ❑Wholesaler(02) <br /> ❑ Institution (S2) ❑ Summer Camp (T3) ❑ Other area (09) <br /> ❑ Medical Facility(S3) ® Restaurant(T4) <br /> ❑ Industrial/Agricultural (S4) ❑ Highway Rest Area (T5) <br /> Type of Water System Ownershi <br /> ❑ Federal Government(1) ❑ State Government(3) ❑ Mixed Public/Private (5) <br /> ® Private(2) ❑ Local Government(4) <br /> Type of Water Supply <br /> ®Well (10) ❑Well, Purchased (15) ❑ Lake, Purchased (33) ❑ Spring, Purchased (51) <br /> ❑Well,Stream (11) ❑ Stream, Purchased (24) ❑ Canal (40) ❑ Purchased (60) <br /> ❑Well, Lake(12) ❑ Lake(30) ❑ Canal, Spring (41) ❑ Unknown (70) <br /> ❑Well, Canal (13) ❑ Lake, Canal (31) ❑ Canal, Purchased (42) ❑ Other(99) <br /> ❑Well, Spring (14) ❑ Lake, Spring(32) ❑ Spring(50) <br /> EMERGENCY NOTIFICATION FOR PUBLIC WATER SYSTEM <br /> CONTACT PERSON See 5021 Job Title <br /> Address City State zip Code <br /> Phone#1: ( ) Phone#2: ( ) Phone#3: { ) <br /> PROGRAM ELEMENT 4616 EEE 0 ❑APPLICATIONIAMENDMENT FEE <br /> Permit Valid To INSPECTOR# <br /> ❑ Check# Amount Paid Date �} Invoice# <br /> ❑ Cash REVIEWED BY: ACCOUNTING OFFICE L% DATE: 3 7 <br /> EHD 46-03 PWS MASTER FILE-BLUE <br /> 10/12/07 <br />