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WATER SYSTEM DECLARATION <br /> FACILITY ADDRESS: LD L LL 2`D <br /> STREET / y CITY ZIP <br /> I <br /> FACILITY BUSINESS OWNER: O�t�S <br /> NAME <br /> PROPERTY OWNER: K A 11- Usc 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): I <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: 4 <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 -STEP OCT NOV DEC <br /> Number of yearlong residents: G. <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 /> s The well serves at least 25 of the same persons (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 (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 t e 'rrdic ted on this form. q <br /> FACILITY BUSINESS/PROPERTY OWNER: 1\ . 4 I l ` I U7 <br /> SIGNATURE DATE � <br />