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�-SANJOAQUIN COUNTY ENVI M�NTL HEALTH DEPARTMFF_-,ASTERFILE RECORD INFORMATION FORUBLIC WATER SYSTEM <br /> ❑New Public Water System at Existing Facility ❑New Public Water System and New Facility <br /> Facility ID FA Program Record ID PR <br /> Facility Address <br /> (Please check the appropiate description and specify size,number of units and pertinent information) <br /> PUBLIC WATER SYSTEM PROGRAM 4600 <br /> APPLICATION <br /> ❑New Small Community Water System(SOWS)(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)(467 1)=>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(RI) ❑ 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(TI) ❑ Interstate Carrier(01) <br /> ❑ School(S 1) ❑ 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 /> TvRe of Water Supply <br /> ❑Well(10) ❑Well,Purchased(I5) ❑Lake,Purchased(33) ❑ Spring,Purchased(5 1) <br /> ❑Well, Stream(11) ❑ Stream,Purchased(24) ❑ Canal(40) ❑Purchased(60) <br /> ❑Well,Lake(12) ❑Lake(30) ❑ Canal, Spring(4 1) ❑ Unknown(70) <br /> ❑Well,Canal(13) ❑ Lake, Canal(3 1) ❑ Canal,Purchased(42) ❑ Other(99) <br /> ❑Well, Spring(14) ❑ Lake,Spring(32) ❑ Spring(50) <br /> EMERGENCY NOTIFICATION FOR PUBLIC WATER SYSTEM <br /> CONTACT PERSON Job Title <br /> Address City State Zip Code <br /> Phone#1: ( ) Phone#2: ( ) Phone#3: ( ) <br /> Program Element Fee ❑Application/Amendment Fee <br /> Permit Valid To Inspector# <br /> ❑Check# Amount Paid Date Invoice# <br /> ❑ Cash Reviewed By Accounting Office Date <br /> EHD 46-02-003(SLUE) PWS MASTERFILE RECORD <br /> 6/6!2003 <br />