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q SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT His1868 East Hazelton Avenue, Stockton , CA 95205-6232 s Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov. org/ehd l .' ! Fy.,:` -- WATER SYSTEM DECLARATION Facility Name: Wats i n�t Facility Address : i lbl o Lo TIgQQ 11C L-.Ocu ` I5 -b S(�+�Cu �X ' A (�� City Zip Code Facility Business Owner: � V\I I Property Owner: 700 Lcxi��iee � 5a�K) Street City Zip Code FACILITY INFORMATION py1 . Number of houses , mobile homes, or(;O pied buildings served by the water well (s) : 2. Number of employees at the facility per shift: Number of shifts: 3. Number of employees at the facility per month, if variable: January April July October \ February May August November 0 March June September December 4. Number of days that the total number of customers, visitors and employees that frequent the facility exceeds 24 in each month (i . e. , 25 or more customers on 6 days in January , or 25 +/6 days) : January April July October February,: I May August November March June September. 1 December 5. Number of yearlong residents: 6. Number of residents per month , if variable: January April July October February May Augus4 November March June September December WATER PROVISION INFORMATION Using the information listed above, please check the box that best describes the water provision at the facility: ❑ The well serves at least 15 connections used by yearlong residents or it regularly serves at least 25 yearlong residents (Community). ❑ The well serves at least 25 of the same persons (i.e., employees, students) over six months per year (NTNG). ❑ The well serves 25 or more persons (not the same persons, i .e., customers, visitors) at least 60 days per year (TNC) . ❑ The well serves five (5) to 14 connections (i.e. , houses, mobile homes, etc) and does not serve water to an average of 25 individuals daily for more than 60 days out of the year (State Small). XThe well serves less than five (5) connections and regularly serves 24 or less individuals daily through out the year. I (We) declare under penalty of perjury that the statements on this application are correct to my (our) knowledge . It is the owner's responsibility to notify this office if the operation of the facility changes to the extent it now meets a different definition of a pltblic water system then indicated on this form . Facility Business/Property Owner: /� z Date : J Signature EHDWATER SYSTEM DECLARATION 4130/7212