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*S'TATE OF CALIFORNIA <br /> APPLICATION <br /> FOR <br /> DOMESTIC WATER SUPPLY PERMIT <br /> FROM <br /> Applicant: <br /> (Enter the name of legal own person(s)or organization) ®F <br /> ® � SQA TyF <br /> Address <br /> System Name: -e— 0 <br /> W F <br /> � m <br /> System Number: s 00 <br /> TO: San Joaquin County Environmental Health Department + <br /> 304 E. Weber Ave, Stockton Ca., 95202 ' <br /> IF0RN�A <br /> Pursuant and subject to the requirements of the California Health and Safety Code, <br /> Division 104, Part 12, Chapter 4 (California Safe Drinking Water Act), Article 7, Section 116525, <br /> relating to domestic water supply permits, application is ))hereby made for a <br /> domestic water supply permit to operate r a n�ver\T gor\ rh h t''�" <br /> (Applicant should state the type of system,e.g.,community, <br /> transient-noncommunity,or nontransient-noncommunity,and the proposed area of services. This application will also be used <br /> for a change in ownership application. <br /> I (We) declare under penalty of perjury that the statements on this <br /> application and on the accompanying attachments are correct to <br /> my (our) knowledge and that I (we) are acting under authority and <br /> direction of the responsible legal entity under whose name this <br /> application is made. <br /> Signed By: <br /> E)' <br /> Title: �- <br /> Address: <br /> ® CQ \Q 6 <br /> Telephone: '� �! '1 — X1 ®1 L) <br /> Dated: —'� — Q 7S DDW:05/2000 <br />