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Apr, 23. 2009 10: 35AM LAI'' ^IFICES OF W, RUSSELL FIELDS <br /> �22 q WATER SYSTE I DECLARATION <br /> FACILITY ADJ I Woo� IC ( n� <br /> rRE <br /> CITY ZIP <br /> FACILITY BUSINESS OWNER; <br /> NAME <br /> PROPERTY OWNER: Im U S 5 �' <br /> Please complete the following: NAME <br /> Number of houses, mobile homes, or other occupied buildings served by the water well(s): y� <br /> Number of employees at the fa�ility per ahlft: I,�—) Number of shifts: <br /> Number of employees at the facility per month, If variable; <br /> JAN— <br /> FEB—�- --MAR Q APR Q MAY JUN <br /> Jul,�_ AUG G SEP— OCT NOV�— DEC C� <br /> umber of days that the total nu bar of customers, visitors and employees <br /> In each month: that frequent the faculty exceeds 24 <br /> (i.e. 25 or more customers on 6 days in January, or 25•r/6 days) <br /> JAN FE8 MAR-2_IL APR lV MAY <br /> _ JuN.�_1c� <br /> JUL__/& SEP` OCT ` NOV � DEC _ <br /> Number of yearlong residents: <br /> Number of residents per month, if variable: <br /> JAN_ FEB `MAR— APR MAY <br /> JUN <br /> Jul_,•„� — AUG SEP�� OCT _ NOV <br /> �� DEC <br /> Using the Information listed above please check the box that best describes the water provision at tl;e tacillty. <br /> The well serve$ at least 19 connections us®d b <br /> residgnto <br /> Or it regularly serves at Ie at 25 yearlong residents r (Community) <br /> o The well serves at least 2S 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 nersrsr,rt� i•e• customers, visitors <br /> year. (TNC) )at least 80 days per <br /> C7 The well serves f' torcn) <br /> s (I,e, houses, mobile homes, etc.) and does not serva water tc an <br /> average of 2g Individuaore than 6o days out of the year. (State Small) <br /> Tne w®II serves less thtions and regularly serves 24 or less Individuals daily threu�hout the <br /> year. (Private water syste ). <br /> I (We)declare under penalty of pe jury that the statements on this application are correct to my(our) knowledge. <br /> It Is the owner's responsibipty to no ify this office if the operation of the facility c nges to the extent It now meets a <br /> different definition of a public water sy m th dila on this form, <br /> FACILITY BUSINESS/PROPERTY OWNER: 4AT�—E <br /> 3/Ut/ <br /> IGNA UR <br /> TO 3Jtld V3 EEbE89b60? 6;-LO 6006/E6/b0 ■E <br />