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R 1� Fmc <br /> WATER SYSTEM DECLARATION <br /> FACILITY ADDRESS: -1 DO R%v'2r R o (6n S 4� <br /> STRE CITY ZIP <br /> FACILITY BUSINESS OWNER: �E,lt►� <br /> NAME <br /> PROPERTY OWNER: l I,;e- I e-• <br /> NAME <br /> Please complete the following: <br /> Number of houses, mobile hon ies, or other occupied buildings served by the water well(s): 1 <br /> Number of employees at the f icility per shift: ; Number of shifts: i <br /> Number of employees at the f cility per month, if variable: <br /> JAN FEB MAR APR. MAY JUN <br /> JUL� AUG SEP OCTNOV DEC <br /> Number of days that the total n imber of customers,visitors and employees that frequent the facility exceeds 24 <br /> in each month: <br /> (i.e.25 or more customers on t days in January,or 25+/6 days) ft <br /> JAN , ` FEB MAR D ,. APR__Q_ MAY V JUN <br /> JUL U AUG SEP 0 OCT O NOV Q DEC 4 <br /> Number of yearlong residents _ _ <br /> Number of residents per mon ,if variable: <br /> JAN FEB MAR APR MAY JUN <br /> JUL— AUG SEP OCT__. NOV DEC <br /> Using the information listed abo ve. please check the box that best describes the water provision at the facility. <br /> ❑ The well serves at leael 15 connections used by yearlong residen <br /> Or it regularly serves at least 25 yearlong resi en .(Community) <br /> ❑ The well serves at least 25 of the saa ersons(i.e,employees,students)over six months per year <br /> (NTNC) <br /> ❑ The well serves 25 or rr Dre persons Unot the sameAwrsons, I.e.customers,visitors)at least 6o days per <br /> year. (TNC) <br /> ❑ The well serves five to 4 onn ti ns(i.e. houses,mobile homes,etc.)and does not serve water to an <br /> average of 25 individual daily for more than 60 days out of the year. (State Small) <br /> The well serves less thi n 5 connections and regularly serves 24 or less individuals daily throughout the <br /> year. (Private waters em). <br /> 1 (We)declare under penalty o perjury that the statements on this application are correct to my(our)knowledge. <br /> It is the owner's responsibility tc notify this office if the operation of the facility changes to the extent it now meets a <br /> different c Onition of a public water system then ' icated on this form. <br /> FACILITY BUSINESS/ ROPERTY OWNER. L )z-2i-�D -4 <br /> SIGNATURE DATE <br /> TO 39Vd 1S3N SaNIS VILS6696OZ Z9:T0 VOOZ/8Z/ZT <br />