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®® 08/19/2014 16:10 12099573791 HEAD START PAGE 01/01 <br /> EU■ <br /> ' AUG 19 2014 <br /> ENVIRONMENTAL HEALTH <br /> Sy WATER /SYSTEM DECLARATION PERMIT/PEER ICES <br /> FACILITY ADDRESS; /L3tW U M45MA,1 Ct fo f� 15k-1L- <br /> STREET <br /> 5 —1STREET '�I C`17YY r,, J ZI/P�' <br /> FACILITY BUSINESS OWNER: tCWII� (U �� `'"WK y tie <br /> NAME <br /> PROPERTY OWNER: 90rJh-Q lf ��ytt51 LL r �c1i�s 1{O Yl <br /> NAME <br /> Please complete the following: <br /> Number of houses, mobile homes, or other occupied buildings served by the water well(s); <br /> Number of employees at the facility per shift;S Number of shifts: <br /> Number of employees at the facility per month, if variable: <br /> JAN FEB MAR / ' _ APRMAY._o JUN <br /> JUL-6 , AUG—L--SEP OCT _ NOV 6 DEC , <br /> Number of days that the total number of customers, visitors and employees that frequent the facility excaeds 24 <br /> in each month: <br /> (i.e. 26 or more customers on 6 days in January, or 25+/6 days) <br /> JAN .�l FEB -C' MAR A27 APR ? MAY ,,Cy�a�yy/ JUN <br /> JUL•� AUG -AO'' <br /> SSSEP �� OCT L' NOV C / DEC <br /> Number of yearlong residents; <br /> Number of residents per month, if variable: �. <br /> JAN FEB_,/Ir MAR APR MAY )e7- ,JUN <br /> JULAUG_ SEP OCT NOV DEC <br /> Using the information listed above, please check the box that best describes the water provision at the facility. <br /> U The well serves at least 15 connections used by yearlong rasldents <br /> Or it regularly serves at least 25 yearlong residents. (Community) <br /> ❑ The well serves at least 25 of the same persons(i.e_ employees, students) over six months per year <br /> (NTNC) <br /> 0 The well serves 25 or more persons (not the same persons, i.e. customers, visitors)at least 60 days per <br /> year. (TNC) <br /> 13 The well serves five to 14 connactlons (Le, houses, mobile homes, etc.) and does not serve water to an <br /> average of 25 individuals daily for more than 60 days out of the year. (State Small) <br /> The well serves less than 5 connections and regularly serves 24 or less individuals daily throughout-the <br /> year. (Private water system), <br /> I (We) declare under penalty of perjury that the statements on this application are correct to my(our) knowledge. <br /> It is the owner's responsibility to notify this office if the operation of the facility changes to the extent it now meets a <br /> different definition of a public water system then indicated on this form. <br /> FACILITY BUSINESS/PROPERTY OWNER: I1fL� <br /> Si NATURE OA <br /> Received Time Aug. 19. 2014 4: 04PM No. 6861 <br />