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I <br />4 y ' <br />Dated <br />By. <br />Address <br />Phone (day) F <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 />A Division of San Joaquin County Health Care Services <br />19 <br />Applicant z^ <br />(Address of legal owner, person(s), or organization) <br />To San Joaquin County Public Health Services, Environmental Health Division: <br />Pursuant and subject to the requirements of Division 5, Part 1, Chapter 7, California Safe <br />Drinking Water Act of the California Health and Safely Code (CHSC) relating to domestic waler <br />supplies, application is hereby made for a permit to: <br />-------- <br />a, <br />Phone (night) f- <br />PUBLIC WATER SUPPLY PERMIT APPLICATION <br />Application from a aJ <br />(Name of utility) <br />^Enlcr the name of the legal owner, pcrson(s), or organization) <br />Address <br />- 'IO ci • <br />IaJiOPRci? c[ <br />■flFir bX-icOC/Wj l/l/ft-TZX 5/ftv)'brt-£ [>c> ,__________ <br />-----An 5^/^A 47r///^// ^ <br />(Applicant must state specifically what is being applied for - whether to operate a public waler system, to construct <br />new works, to usc.cxisting works, to make alterations or additions in works or sources. Note Section 116530 CHSC <br />Cd 3,15 3nd sPcc'flca“ons to accompany all applications to construct or modify a public water <br />o j oldlH 5). j <br />direction of the legal responato enllty un(|Cr whose name this application is made <br />Title <br />■ S c/a <br />/V A ' f’T.- <br />r* Rh