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I [Domestic Water Supplies. Form A3. Indiv- l atio.--;irms] l STATE OF CALIFORNIA BOARD OF PUBLIC HEALTH CtU�MlF Application rorn. L_ -------------------------------- - .� f Name of applicant,and if not an individual,a statement as to whether partnership or corporation i To the SAN JOAQUIN LOCAL F;EALIM DISTRICT 1601 EAST IiAZELTON AVENUE STOCKTON 5, CALIFORNIA I i Pursuant and subject to all of the terms, conditions and provisions of Division 5, Part 1, Chapter 7, Sections 4010 i to 4035 of the California Health and Safety Code and all amendments thereto, relating to domestic water supplies, application is hereby made to said State Board of Public Health for a permit to___use_—e_`_iF!tin :'102^st-'`cc.'= _ Cu.__ist_in of c e, deed �1 > ' -= ='i= r ., to 114_!i_Sin-le ca_3_ w _ _r± .. _ -- .. _ __-_________ ____________ _ _______ Applicant must state specifically what is being applied for—whether to construct new works, to use existing works, to make alterations or additions in works or sources and St. _ 1 O ____ ___ ____—_ _________________ __—_!__ --__'_-)_____�_________ _____________ ___ __��____________________—___________________________________________________ stare nature of improvement in works. Enumerate definitely source or sources of supply, kind of works used or considered (if known) and specify the locality to be served. - i Additional sheets may be attached. ______________-_-----------_________—___—___-__-____________--_________________—____________-_____�___________-__--------- - I .. -------------....------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Dated--------- -- ------- ------ ---------- 19__x7_. A,' --------------- ------- --- IF BY CORPORATION, CORPORATE SEAL HERE 2C-,' i:.-_,nk ~" n,• f •A E �. . 2 __= Wiz= = 1.-O=n1 —- n_ Poet-office address NOTES If this application is made by a corporation, it must be signed in the name of the corporation by its duly accredited officer or officers, and must be accompanied by a resolution of the board of directors of such corporation authorizing the application to be made. This resolution must be made substantially in the form furnished by the State Board of Public Health (Domestic Water Supplies Form A4). If this application is made by a partnership, all of the members must sign. If this application is made by more than one individual,all must sign. In all cases the post-office address of the applicant must be giv n and the execution of the application must be acknowledged before a Notary Public. 26349 5-60 6M SPO (5-f•5o) FORM SE-1520