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f R <br /> 0AQ U l Environment(- Health Department <br /> COUNTY <br /> %_71,eatness graws here, PA 1800145 <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: � �,J�� Lc,- Es' , .�Lca <br /> Facility Address: l '�2 � �� � �_� a Cs3-o_ -yl <br /> Street City Zip <br /> Facility Business Owner Name: ��� ��Q� Cv` � �� Phone:_2 -7 —( <br /> Property Owner Name: �i1�s, ���Q Phone: ,7_z-qy,_"70-1­lS <br /> Property Owner Address: b}ry� <br /> Street City Zip <br /> WATER PROVISION INFORMATION <br /> 1. Number of houses, mobile homes, or other occupied buildings served by the water well(s): <br /> 2. Number of employees at the facility per shift: Number of shifts: <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January April July October <br /> February May August November <br /> March June September December <br /> 4. Number of days that total number of customers, visitors and employees frequent-the facility per mon.th: <br /> January 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, if 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: % , ( Date: '" <br /> Signature <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www,sjcehd.com <br />