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WATER SYSTEM DECLARATION FACILITY ADDRESS: STREET CITY ZIP FACILITY BUSINESS OWNER: NAME PROPERTY OWNER: NAME Please complete the following: Number of houses, mobile homes, or other occupied buildings served by the water well(s): Number of employees at the facility per shift: Number of shifts: Number of employees at the facility per month, if variable: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 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) JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Number of yearlong residents: Number of residents per month, if variable: JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Using the information listed above, please check the box that best describes the water provision at the facility. 171 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 (NTNC) 171 The well serves 25 or more persons (not the same persons, i.e. customers, visitors)at least 60 days per year. (TNC) 13 The well serves five 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) 1:1 The well serves less than 5 connections and regularly serves 24 or less individuals daily throughout the year. (Private water system). 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 public water system then indicated on this form. FACILITY BUSINESS/PROPERTY OWNER: SIGNATURE DATE