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JUN-14-99 MON 10,:41 A— PURVIANCE- DRIL <br /> P'13574 P- 82 <br /> A JA.A UIN COUTY PUBLIC HEALTH SERIVCES <br /> g� "�IIRONMENTAL HEALTH DIVISION <br /> 304 E. WEBER AVE.—3ao FLOOR—STOCKTON, CA 95202 <br /> PUBLIC WATER SUPPLY PERMIT APPLICATION <br /> Application From CALVARY BIBLE CHURCH <br /> (Name of Utility) <br /> Applicant CALVARY BIBLE CHURCH - — <br /> (Enter the name of the legal owner,person(s), or organization) <br /> Address P.O. BOX 1503 LODI, CA 95241 <br /> (Address of legal owner, person(s), or organization) <br /> 1 o San Joaquin County Public Health Services, Environmental Health Division: <br /> Pursuant & subject to the requirements of Division 5, Part 1, Chapter 7, California Safe Drinking <br /> ':Fater Act of the California health& Safety Code (CHSC) relating to domestic water supplies. <br /> application is hereby made for a permit to: <br /> Construct New well pumas tank & plumbing for <br /> Calvary Bible Church <br /> (Applicant must state specifically what Is being applied for-whether to operate a water system,to construct new <br /> works,to use existing works,to make alterations or additions in works or sources. Note Section 116530 CHSC, <br /> requires detailed plans and specitications to accompany all applications to construct or modify a public water <br /> system(s),) <br /> Dated JUNE 15, 1999 <br /> I (we)declare under penalty or perjury that the staternents on this application& on the <br /> accompanying attachments are correct to my (our) knowledge & that I (we)are acting under <br /> aut tty direction of the responsible legal entity under whose name this application is made. <br /> liy n I <br /> Title --- <br /> Address P- o. BSI '5 3. CYW-/ ,�} g5a Y/- /s o 3 <br /> Phone (day) 4209) 76 7- ?9 / phone(evening) r,.Z 36g yy <br /> RNwnrr>vNrc rm <br /> I <br />