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iX? / ^><7/(J <br /> <br /> <br />Dated <br />A Division of San Joaquin County Health Care Services <br />•<v <br />PUBLIC HEAlTH SERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIVISION <br />Karen Furst, M.D., M.P.H., Health Officer <br />304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br />209/468-3420 <br />Applicant <br />lEnler the name <br />Add rcss , <br />(Address of legal owner, person(s), or organization) <br />To San Joaquin County Public Health Services, Environmental Health Division: <br />('a r <br />Phone (night) <br />Pursuant and subject to the requirements of Division 5, Part 1, Chapter 7, California Safe <br />Di inking Watci Act of the California Health and Safety Code (CHSC) relating to domestic water <br />supplies, application is hereby made for a pennit to: <br />___An Z/Z//4// <br />(Applicant must state specifically what is being applied for — whether to operate a public water system, to constructPCE-UEV <br />new works, to usc»cxisting works, to make alterations or additions in works or sources. Note Section 116530 CHSC <br />requires detailed .plans and specifications to accompany all applications to construct or modify a public water <br />ENVIRONMENT HtB <br />I (we) declare under perjury that the statements on this application and on the accompanying <br />attachments are correct to my (our) knowledge and that I (we) are acting under authority and .< <br />direction of the legal responsibly entity under whose name this application is made. <br />By <br />Till e Z/'____________ <br />- -——---------------— <br />Address zXX3 S <br />Phone (day) F <br />PUBLIC WATER SUPPLY PERMIT APPLICATION <br />App 1 icalion from [! a / aSS _______________ <br />(Name of utility) <br />_________<_____________ <br />of the legal owner, person(s), or organization)