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- - <br /> � � 1 <br /> WATER SYSTEM DECLARATION <br /> FACILITY ADDRESS : 78 (Yq t HRhhey Lk, L4)Ai 95�Ay6 <br /> 1 . 1 <br /> STREET CITY ZIP <br /> FACILITY BUSINESS OWNER: J�att�( C at^ Melme } <br /> NAME <br /> PROPERTY OWNER: 5u I" Q <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: Number of shifts : <br /> Number of employees at the facility per month , if variable: <br /> JAN FEB MAR APR MAY JUN <br /> JUL AUG SEP OCT NOV DEC <br /> Number of days that the total number of customers, visitors and employees that frequent the facility exceeds 24 <br /> in each month : <br /> (Le . 25 or more customers on 6 days in January, or 25+/6 days) <br /> JAN FEB MAR APR MAY JUN <br /> JUL AUG SEP OCT NOV DEC <br /> Number of yearlong residents : D <br /> Number of residents per month , if variable: <br /> JAN d FEB d MAR 0 APR D MAY JUN <br /> JUL D AUG SEP OCT d NOV d DEC <br /> Using the information listed above, please check the box that best describes the water provision at the facility. <br /> ❑ The well serves at least 15 connections used by yearlong residents <br /> Or it regularly serves at least 25 yearlong residents. (Community) <br /> ❑ The well serves at least 25 of the samepersons (i .e . employees , students) over six months per year <br /> (NTNC) <br /> ❑ The well serves 25 or more persons (not the same persons , i .e. customers , visitors) at least 60 days per <br /> year. (TNC) <br /> ❑ The well serves five to 14 connections (i.e. 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 I (We) declare under penalty of perjury that the statements on this application are correct to my (our) knowledge. <br /> j 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 /> I different definition of a public watery system therm indicated on this form . <br /> FACILITY BUSINESS/ PROPERTY OWNER: q (Ltysnn.-/ J m , 5 - 1S- 1 3 <br /> SIGNATUFZE DATE <br />