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Apr, 23. 2009 5. 11PM LAV" '�FICES OF W. RUSSELL FIELDS No, 3052 P. <br /> M <br /> WATER SYSTEM DECLARATION <br /> FACILITY ADDRESS; W oa�bf-( >� C Ra ��Mar_I <br /> CITY <br /> / ZIP <br /> FACILITY BUSINESS OWNER; <br /> NAMfJE / <br /> PROPERTY OWNER; ��fA <br /> Please compete the following: NAME <br /> NUmbsr of houses, mobile homes, or other occupied buildings served by the water well(s):_ <br /> Number of employees at the f2clllty per shift:— r Number of shifts: <br /> Number of employees at the faclllty per month, if variable: <br /> JAN C7 FES 0 MAR � _ APR_ MAY D JUN <br /> JUI�� AUG—_C) SEPa CD rl~~ <br /> OCT ^ NOV d DEC V <br /> Number of days thet the total number of customers, visitors and employeas 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- _ FE13_ MAR APR MAY <br /> JUL AUG <br /> TSEp OCT <br /> —�= NOV <br /> Number of yearlong residents: <br /> Number of residents per month, If variable: <br /> JAN_ FEB—MAR APR MAY— JUN�� <br /> JUL AUG�SEP _ CCT— NOV DEC <br /> -- <br /> Using the Information listed above, pleese check the box that best describes the water provision at the facility, <br /> d The well Serves at least 15 connections used by yearlong EtILqgnts <br /> Or it regularly serves et least 25 yearlong r s. (Community) <br /> Ca The well serves at least 25 of the ARMEpersons (I.e. employees, students)over-wix months per year <br /> (NTN C) <br /> The well serves 25 or more persons (not the same ner�ons, ).e. customers, vialtors) at leas: 60 days per <br /> year. (TNG) <br /> o The well serves five to 14 con nec i s (i.e. houses, mobile homes, etc.) and does not serve water to an <br /> average of 25 Indlvidusls 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 indivhluals 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 cnges to the exlent it now meets a <br /> different definition of a public wate7IGNATUR <br /> m th dJce an this form. <br /> FACILITY BUSINESS/PROPERTY OWNER: #o-:5/&� <br /> ATE <br /> To 39Cd QH3 ££b£89b69Z 65:L0 600�lcZ/70 <br />