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SAN.:-.JOAQUIN Environmental Health D- epL <br /> COUNTY �,rtr����� <br /> , .x'{� <br /> `'•�ti[`�-o�cc:' Gr;:�tr�cs� �rotvs ,here, <br /> MATER <br /> 6UN7Y— <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: <br /> \j <br /> Facility Address- <br /> S•r <br /> Facility Business owner Name: eel <br /> '3 Zip <br /> Phone: 2-c ci - e)el I <br /> Property Owner Name: Phone:­)_�� <br /> -LIS <br /> Property Owner Address.- <br /> StreetCi Zip <br /> WATER PROVISION INFORMATION <br /> 1. Number of houses, mobile homes, or other occupied buildings sensed by the water well"s): 01 <br /> 2. Number of employees at the facility per shift: Number of shifts: 0 N E 6N L <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January Ll April July I I October <br /> February May August 1 November <br /> March i l,; June September December <br /> 4. Number of days that total number of customers, visitors and employees frequent the facilitypermonth: <br /> Canary April July October <br /> February May August November <br /> March June September December <br /> 5. Number of yearlong residents: <br /> 6. Number of residents per month, H variable: <br /> January April July October <br /> February May August November <br /> March June September December <br /> I declare under penalty of perjury that the statements on this application are correct to my knowledge. It is the <br /> owner's responsibility to notify this office if the water provision information of the facility changes. <br /> Facility Business,!Property Owner: CO W iV Ckeo- C, <br /> 1868 E. Hazeitor Avenue I Stockton, California 95125 I T 209 468-3420 1 F 203 464-10138 <br />