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W TER SYSTEM DECLARATION <br /> FACILITY ADDRESS: Jl �` / <br /> STREET CI Y ZIP <br /> FACILITY BUSINESS OWNER:_ ( k <br /> NAME <br /> PROPERTY OWNER: <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 /> (i.e. 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: <br /> Number of residents per month, if variable: <br /> JAN FEB MAR APR MAY JUN <br /> JUL AUG SEP OCT NOV 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 /> 17-1 T' e well serves at leas 25 of the same persons (.e. employees, students) over six months oer year <br /> i�ITNC <br /> ._n` ,,ea ser/ss 25 /n r customers,—_- .��. irrS S,J, i.e. stomers, Visitors`) at least 6t. 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 mcra than 50 days out of the year. (State -Small) <br /> The-,,-ie!! serves less than.. 5 ccrnectionis cr _nlj r , cp _ -1J nr fa5S <br /> ...u,r ,it Uye1V IJl 111E <br /> y22r. ;Pr�rate water �yste,;;). V � <br /> I tWe)i declare under penalty of perjur, that the stat,,; n. , ct onlicailon are correct to my(our) knoluledce <br /> I`esponsib:lity o notify tris office if the upel ti I <;' ne facility changes to the extent it now meets a <br /> different definition of a public water then Indicated or, this orm. <br /> ACIL!TY BUSINESS/PROPERTY OWNER: 3 !? <br /> CI„,1`TI ARG <br />