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r 1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DIVISION <br /> MASTERFILE RECORD INFORMATION FORM EH 00 69 PWS l <br /> [I New Public Water System at ExistingFacili ©New Public Water System and New FaciIi <br /> S <br /> dei ✓ % <br /> Fac 4, <br /> .ID x, i"�!t 1r ! H� ; ".. 'k+ ,`Pr,O ramRecor.d<IDst �lr�� <br /> Facility Address % O uQ 2- k6u <br /> (Please Check the appropriate description and specify size,numb"f units and pertinent information.) <br /> PUBLIC WATER SYSTEM PROGRAM(4600) <br /> APPLICATION <br /> ❑ New Small Community Water System(SCWS)(4603) Dates of operation to <br /> ew Non-Community Water System(NCWS)(4602) Dates of operation to <br /> ❑ Permit Amendment(4604) <br /> PERMIT <br /> i <br /> ❑ State Small Water System(4644)5-14 Service Connections MD ��� ��]�n <br /> ❑ SCWS(4521) 15-24 Service Connections �I L/ [UJ <br /> ❑ SCWS(4622)25-99 Service Connections OCT <br /> 1:1SCWS(4623) 100-199 Service Connections 1 ZOOO <br /> ❑ Non-Transient NCWS(4630) Serving the same 25 or mare Individuals=>180 days per yea'ENVIRONMENT HEALTH <br /> ransient NCWS(4633)=>25 Customers/Consumers per day PERMIT/SERVICES <br /> surface Water System(SCWS)(4670) 15-199 Service Connections <br /> ❑ Surface Water,System(NCWS)(467 1)=>25 Consumers=>60 days per year <br /> ❑ CURFFL NCWS(4616)-Food Facility without Water/IceeryiaP fsc��stnmerc -- <br /> ., <br /> TONY COYN E, INC. M 5091 <br /> DBA COYNE CONSTRUCTION � <br /> LICENSE NO.373068 All <br /> A P.O.BOX 2701 1 y <br /> LODI,CA 95241 f V 1 r1O 90.844-1211 <br /> PH,209-333-0404 DATE f V i (D <br /> PAY <br /> TO THE <br /> ORDER OF <br /> I i <br /> i <br /> I <br /> ' i 1 —DOLLARS <br /> ' <br /> FARMERS&MERCHANTS'BANK <br /> Ii <br /> Of:CENTRAL CALIFORNIA <br /> � <br /> LODI OFFICE ,� ,I --------- --- <br /> I`� LODI,CA 95240 <br /> FOROr <br /> i.4 m00 SO 111' -1: 12 1 10aLILI 11: 00 18 2 7 6 1111 <br /> r^';,„;ur ...-.��+' asi1L�:� n•.e x�r��.�.Sttc= ice. --�=m•.+�?�Jr�_.e__ -- - <br /> . LJ,Canal,Purchased(42} ❑ Other(99) <br /> El Well,Spring(14) 13 Lake,:Spring(3 2)` ❑"Spring(50):;. <br /> EMERGCNcr NOTIFICATION FOR PUBLIC WATER SYSTEM <br /> CONTACT:PERSON (� J . �ulbc' _� JohTitle <br /> Address --•I t7 ("J • �-�i�3 i� `�. �. City State(' Zip C[U 4iA2 - <br /> Phone#1:J j Phone#2:2-6rA &f (C:i. G��✓C'i Phone#3: <br /> I'1tOGRA117 E{E1111 NT`. D `<,, QPlccatron/Amendment- REI;'. VLJ' <br /> Pj_P,MIT.VAI ID: t0 INSt'ECTOIZ# <br /> ❑ Check# AMOUNT PAID,x Date ;' INVOICE# <br /> ❑ Cash" Revl>WEI). Y- _ AccOuNTiNGOFFIC6 _ w � Date <br /> PWS EH 0069 Bluc form.doc `/3' �.��� - Rcv.07/07/99 <br />