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Sheet 1 <br />Date... <br />(1) Community or Area Served <br />Owner. <br />(3) Local Representative .. <br />(Till.) <br /> Address <br />(S’!i <br /> <br /> <br /> <br /> <br />(c) Pumping Stations <br />(e) Distribution System <br /> <br /> <br />STATE OF CALIFORNIA <br />L. .JARTMENT OF PUBLIC HEALTH <br />INFORMATION TO ACCOMPANY <br />APPLICATION FOR WATER SUPPLY PERMIT <br />(Small Water Systems) <br /> <br /> <br /> <br />(Give brief description and location) <br /> <br />(d) Reservoirs <br />(2) Name of Water System <br /> <br />Owner’s Address <br />(Name) ✓ <br /> _ <br />...County..... <br />^Submit map if available) <br />(4) Principal Features of System <br />(a) Source of Supply <br /> <br />/ . A~nn c> l<s>ir <br /> <br />(b) Treatment Works ...jQJC.ii..