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"�a�rtm f aI�t1` <br /> :a n.4 ........... <br /> v�.rbnrrieha�:, ana_ em . <br /> 31 East Ch2nnel Strccl Room 270 SlOcklon CA 95202 (209)948.7230 <br /> Application from; s S 1*�_a_F r <br /> Applicant: <br /> U � <br /> Address: <br /> 3 4V <br /> To: DEPARTMENT 4F HEALTH SERVICES , <br /> Division of Drinking Water and Environmental Management <br /> 31 East Channel Street Room 270 e <br /> Street, <br /> 1Fol;t�� <br /> Stockton, CA 95202 <br /> Pursuant and subject to the requirements of Division 5, Part 1, Chapter 7, <br /> Water and Water Systems of the California Health and Safety Code [CHSC] <br /> relating to domestic water supplies,- application is hereby made for a ' permit <br /> to <br /> I (We) declare under penalty of perjury that <br /> Dated 19 the statements on this application and on <br /> the accompanying attachments are correct to <br /> my (our) -knowledge and that 1 (we) are <br /> acting under authority and direction of the <br /> responsible legal entity under whose name <br /> this application is made. <br /> By <br /> Title <br /> Address <br /> iMl V/u/IM.IdC <br /> Telephone <br />