HomeMy WebLinkAbout1950-07-25 Min Ord - Board(Domestic Water Supplies. Form Al. Municipal Carp
a
a or Civil Subdivision]
STATE OF CALIFORNIA
BOARD OF PUBLIC HEALTH
Y A
Applicationfrom __....---__-----------_TX__ CJWft__P b11&__U _tY__TA&+X11A-------------------- -----------------------------------------------------
(Name of municipality or civil subdivision)
organized under--_-.. ----------------- ?_ubJJ4-_Y.tUjet► __- X1 -AQt--QC-- ------------------------- ------------------------------------------
(State whether special charter or under general law, giving c iss and date of incorporation)
To the STATE BOARD OF PUBLIC HEALTH sr
760 Market Street
San Francisco, California
Pursuant and subject to all of the terms, conditions and provisions of Division S, Part Chapter 7, Sections 4010
to 403 S of the California Health and Safety Code and all amendments thereto, relating to domestic water supplies, application
is hereby made to said State Board of Public Health for a permit to__4101-01.___ _ ___�
iservir _ --mod. _ t. e_ t t � �a �. 1t �� _�--te- _._ r r�r�rfaa_w.rwa.+�s •arm. rr • •.ter +�_ _..r
Applicant must state specifically what is being applied for -whether to construct new works, to use existing works, to make alterations or additions in works or sources and
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state nature of improvement in works. Enumerate definitely source or sources of supply, kind of works used or considered (if known) and specify the locality to be served -
Report. --_____-__-_____.
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Additional sheets may be attached.
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Dated
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AFF1X
(Name of municipality civil subdivision, in full)
OFFICIAL SEAL
HERE
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Y
(Signature of chief executive officer with o6cial title and post-ogice address)
Attest:
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(Signature of clerk or corresponding official with title and post-o a address)
------ . -------.--------------------
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NOTES
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40_46; �s_ _________________ -. __ __ _---_--_--
Before making application for permit, such action must be authorized by resolution of the governing board, substantially in the form
furnished by the State Board of Public Health (Domestic Water Supplies, Form A2) and a copy of such resolution, duly certified by the clerk of such
board, must accompany the application.