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Sheet 2 <br />(Source and character, frequency of uw) <br /> <br />(6) Back-Flow Hazard .... <br /> <br />(7) Emergency Provisions... <br /> <br /> <br /> <br />(8) Operating Records.. <br />(ladicau nature and frequency of readings) <br />Avg. Day <br />19 <br />19 <br />19 <br />19 <br />Safe maximum production capacity of supply gals, per y- <br />By......XI. <br />XJXlKTitle <br />ioc.0 nt. .m os. <br />STATE OF CALIFORNIA <br />PEPARTMENTOF PUBLIC HEALTH <br />Population <br />Served <br /> <br /> <br /> <br /> . <br />(For furnishing water during floods, earthquakes, power interruptions and water shortages) <br />No. of Active <br />Connections <br /> <br />No. of Metered <br />Services <br />% <br />Metered <br />(3.14-50) <br />form SE-21 i <br />INFORMATION TO ACCOMPn^Y APPLICATION FOR <br />WATER SUPPLY PERMIT (Small Water Systems) <br />(5) Auxiliary Supplies . <br />Water Used <br />Max. Day <br /> <br />(10) System Data <br />Year <br /> <br /> <br /> <br />... <br />(To prooun ha.ini un.ppro»<d .upplin; progranl, r«gul»t.oo for controlling brek-flov horrrd) <br /> <br /> <br /> <br />(9) Laboratory Tests J 2 <br />(Laboratory making tests, nature of tests and summar^f recent tests) <br />__QjexJL^x. / oi.nci./r^ ____