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*Apr, 23, 2009 10: 23AM LAW urFICES OF W. RUSSELL FIELDS No, 3044 P. 1 <br /> q WATER SYSTEM DECLARATION <br /> FACILITY ADDRESS: 3 f waoa�birPJ <br /> 3TREST ` CITY <br /> ZIP <br /> FACILITY BUSINESS OWNER,- <br /> ---F/ e v �( a 5 <br /> NAm <br /> PROPERTY OWNER: f c�5 S-e �S <br /> Please complete the following: NAMrq <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_ —D— Number of shifts: <br /> Number of employees at the facility per month, if variable: <br /> JAN C FEB a MAR APR APR_ MAY JUN <br /> _ <br /> JUL— AUG C) � <br /> _ SEP d OCT�� NOV DEC CC� <br /> Number of days that the total number of customers visitors and em to <br /> p yeas that frequent the facility exceeds 74 <br /> N each month: <br /> (i,a, 26 or more customers on 6 days in January, or 25+/6 days) <br /> JAN , FEl6� MAR�I APR /0 MAY _ C� <br /> _ JUN—,_,f� <br /> JUL --,L0C <br /> ` AUG Si=A S� -� <br /> OCT NOVA I�EG�� <br /> Number o`yeariong resid*nts: <br /> Number of residents per month, If variable: <br /> JAN_ FEB MAR. APR MAY <br /> J U N�� <br /> JUL_ - AUG SEP OCT. NOV <br /> DEC---. <br /> Using the information listed above, please check the box that best descrlbes the water provision at the facility. <br /> Q The well serves at least 15 connectlons used by yeariong re1iden11 <br /> or it regularly serves at legal,25 yearlong res' n .(Community) <br /> The well serves at least 25 of the same persons <br /> (NTNG) (Le, employees, students)over six months per year <br /> In The well serves 25 or more persons (nQt IIIe same arsons, i.e. Customers, vlsltors)at least 60 days per <br /> year_ (TNC) <br /> © <br /> The well serves to 4 onnections (i,e. houses, rnoblle homes, etc,) and does not serve water to an <br /> average of 25 Individuals daily for more than 60 days out o1 the year. (State Small) <br /> The well serves less than 6 connections and regularly nerves 24 or lass Individuals dally thrpughout the <br /> year. (Private water system). <br /> I (We)declare under penalty of perjury that the statements on this gppllcmdon are correct to my(our)knowledge, <br /> It Is the owner's responsibillty to notify this office if the operation of the facility c rages to the eXtent it now rneets a <br /> different de.finttion of a plubiic w77— <br /> m th dlca on this form. <br /> FACILITY BUSINESS/PROPERTY OWNER: / <br /> UR 4A�T <br /> T6 3Jdd CH3 8ED889760Z 69:L6 668L/8Z/170 <br />