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Application From.<g,c<-r <br />(NAME OF UTILITY) <br />Applicant <br />To San Joaquin County Public Health Services, Environmental Health Division: <br />s?/s7y/-/ <br />Dated <br />7^7By. <br />Title <br />Address <br />- 5 2. a ?Phone (day)Phone (evening). <br />5/94 <br />Pursuant & subject to the requirements of Division 5, Part 1, Chapter 7, California Safe <br />Drinking Water Act of the California Health & Safety Code (CHSC) relating to domestic <br />water supplies, application is hereby made for a permit to <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, STOCKTON, CA 95201-0388 <br />(Applicant must state specifically what is being applied for - whether to operate a water system, to construct <br />new works, to use existing works, to make alterations or additions in works or sources. Note Section 4012, <br />CHSC, requires detailed plans and specifications to accompany all applications to construct or modify a public <br />water system (s). <br />I (we) declare under penalty or perjury that the statements on this application & on the <br />accompanying attachments are correct to my (our) knowledge & that I (we) are acting <br />under authority & direction of the responsible legal entity under whose name this <br />application is made. /) <br />PUBLIC WATER SUPPLY PERMIT APPLICATION <br />'V[ cl <br />(ENTER THE NAME OF THE LEGAL OWNER, PERSON(S) OR ORGANIZATION) <br />Address. Ibex 9S2 ______ <br />(ADDRESS OF LEGAL OWNER, PERSON(S) OR ORGANIZATION)