R 0290
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'- ...-- ,-, -. -'....
[DGmestic Water Supplics. Form A2. Municipal Corp.:. lor Civil Subdivision]
STATE OF CALIFORNIA
BOARD OF PUBLIC HEAL TH
Certified Copy of Resolution 1290
[To accompany application on Form AI]
"Resolved by the__ _________~i.!07__~~g___________________________......._........-.-..........--......--..-......-. -........--..--..----........
(City wllllen, board of trulteel or other governiDJ body)
of the ______.. ______.Ci.~..ot-.ArroJo..n.a-........-..... -.......-----.-..............- --.............------...-- ---......-.--......... ---.--.......-............
(Citr, town or Clown1. etc.)
that pursuant and subject to all of the terms, condi tions and provisions of Division 5, Part 1, Chapter 7, Sections 4010 to 4035
of the California Health and Safety Code and all amendments thereto, relating to domestic water supplies, application by this
.....Gi.~.....be made to the State Board of Public Health, for a permit to....JIIIIII"&y..m.a~.._Hr..}(QI'ka.--.-.-.-..
(City. town or
county, etc.)
_.""._1at.1n2...oL--3-..vella..1.-.NM.,..-IIIICi-..dUItri.bU&\iOll.IIp'_.~.~.~...-
APPHf!JloI Inun 'ht;~1rcaIl1 ,.,bat i. being applIed (or--wh,tber to co,"tnICt." wor1<., to u. aim., work., to make llter_tiODI or addidOll.I i. WOfk. Of SI)1,il'CeI and
..._...ana...ot.~ ar--..aDd..JHID~...4InIN!JL.._...................__.__......................m._................................-
nUt Duun of impfOTement iD work.. Enumerate ddiniuly aource or 10Urces of Iupply, kind of work. uecI or coJUidered (if kno'IVII.) .nd .pecify the loc.lity to ~ lCrTed.
____________________________________________ _____._____~____u___ _______________________________________ _u_______________~_______________d____..____________________--.--------..-----------
Addition.1 .heeu m.y be .u.cW.
_u_.___ ____..___________________._...________.____________.____________.________________________.________._~~~~~__._.~db_~U~_~~~.~~~~.--~~------ ----------~~~~-.....-~~~--~-.---~-.
that the_....................IIQDI'.........._.......__........_..............m....___._of said........~..Af..ArI'oJ.Q..~~~......_........._....-....
(Title of chief executive oJ!icer) (City couaciI, board of trUlteel or other pYUni., body)
be and is hereby authorized and directed to cause the necessary data to be prepared, and investigations to be made, and in the
name of said.___.....__ ___........~~~..__m._._........ ___.__,.. _m.__.....to sign and file such application with the said State Board of
(City, town or county, etc.)
Public Health."
Passed and adopted at a regular meeting of the..._ ___..m.'..J;1Q:._~I~Am. ----.-. ---. ------____........ ___m___"m ------......
(Gonmi.na: body)
of the...........cU7_.oL..Ar.I'oJD-__Qr.aDde... _....__...........__ _on the_ mm~___ __........day of.m..m~_ n_._.m..........19..~~___
(City, to'IVII.or C01lDty, etc.)
[ MFr< ]~.~.h..:~~. -----'-.... ~.. .-.---......-...
OFJlICIAL SEAL , '
HERE . 01\7 of ~ Graade
Clerk of s..d_. ____...n..................____.___....____.........___.... ___............m ...._.___m..m....____.m...__n._m...
(City, town or county. etc.)
(S.2.151) FORM SE-t638 /
.olea I~.I 4M SPC
.. .,-...
- - ~,
(Domenic Water Suppliet, form At. Municipal Corpo, .I. or Civil Subdivision]
STATE OF CALIFORNIA
BOARD OF PUBLIC HEALTH
Application from~____ ---_____ ___o1f.1'__ot__~__OraDCle___ --~~___________~______________________~mm___~_____________________ ______ _____m_~__________
(Name of municipality or civil subdivhion)
organized underl~~___~!CII'___~~~__,,~!__c;.f,~ZJ!!1C1~~~~_cl__!~_),Q,LM'~______________~______
(SUte wnetlte.r special cliat1:er or U4du general law. giviq class and date of incorporation)
To the STATE BOARD OF PuJlLIC HEALTH
760 Market Street
San Francisco, California
Pursuant and subject to all of the terms, conditions and provisions of Division 5, Part 1, Chapter 7, Sections 4010
to 4035 of the California Health and Safety Code and all amendments thereto, relating to domestic water supplies, application
is heteby made to said State Board of Public Health for a permit to-____opwa\e.__!L1d.1I'-1i.1nI.__vaW__YOI'.._ _________________
---~!m-"i-..~_oLJ__1!en~--1.--I'.tI..Y01r--.AI'I4--d1ak'1Im~on__ayJlt.u.-~--incQr_P.QI"aW---__~
Applicant must state specifically 1I'hat is beiq applied for-wLedw~ to c:onltruct IICW worb, to use existing 1I'0rks, to make alterations or additioll' in worb Of toorc:.. ud
--_~__~r_~9_Z~L~~~L~_~~~M__~______________________m,________________~______________________________________~
'tate natUl:'e of improvement in wocks. Enumerate defi.ait:ely 1Io1lr<:e or lOur", of supply, lr.ind of works UHd oc considered (if known) aod specify em loeality to ~ ICfYed.
_~_________________~HW_________H____~_______________ -------_______________~ ___________.~____~________~_______~________~_____~_________~___ ___ _~_~____ _~_ __"____~___n__~ _____ ________________~____
Addjfion~IIhe<<I_y be ..tt~.
_____~_______________n________~___~_______ _________ ___~________ _ _________ ____ __ __.'__ ______________,____ _____'~___~~_~________~___~___~____,,_________.__________________~________________~__________..
_____w_ ~~__~_____ ______.__~________~_________ __~__________________~_____~_______~____~_____~_____________ _______________,_~__~~_______~~__ __________"________________~ ________________~____________.
-- -- > -- - - ----~~----- - -- - - ----~- ---- - - - - - --- -~~-- - -- - ---------------- - - - - -------~ -- - - --~----- -- - -- - -~ -~--- --- - -, - -----~-~-- - - - - - - -- ----- -- -. - - -. -~ ---- - - . - ------- -~- - - - - - -- -- - - - ~ - - - - - --- -- -- -- -~-- -
D.ted_____~g_~L_m____________mmI9 _S~__
[ OFP;""'s.... ] mj!-V-<1~~~_';!.i~!~~;;di;i;i;~:-;.;-i~ii)m m__u
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Attest:
-~,__~-iJ:J-,-jJ umm._ _mm_mm____mmm___ um_mu
(Sigftature of drrk or correspondint official with tide snd pas ~e sdd<<:..)
Clerk
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NOTES
Before making application for permit. such action must be au thorized by resolution of the governing board, substantially in the form
furnished by the State :Board of Public Health (Domestic Water Supplies, FOfm A2) and a copy of such fesolution, duly certified by tbe clerk of such
bOMd, mUlt accompany the application.
l3..:II.JlI) FORM SE.1f53?
~'BI*_II"MPO
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