Laserfiche WebLink
SAN ..,J OAQ U I N Environmental Health Department <br /> —COUNTY----- <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: Vander Schaff Dilt" <br /> Facility Address: 13775 Murphy Road, Escalcn CA 95320 _ — <br /> maj-0City ?Yp <br /> Facility Business owner Name- John Vander Schaaf Phone: (209) 830-3947 <br /> Property Owner Name: Sam Phone: <br /> Property Owner Address: Same —_-. <br /> stmt Dly ziP- <br /> WATER PROVISION INFORMATION <br /> 1. Number of houses, mobile homes, or other occupied buildings served by the water well(s):5 <br /> 2. Nurnber of employees at the facility per shift: Number of shifts; eno prWam 4oeFrlp>lon <br /> 3_ Total number of employees, customers,and vieltors at the facility per month, if variabfe: <br /> Pebruar May ..._.,. JT - _.._. <br /> .}U ly October <br /> ±+ <br /> Jant;isr April i August fJavalnder <br /> March - June - soptember December <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January _ April July October <br /> Y .. Y - r <br /> Februar IIIfEa August Novemb <br /> ,March Jerrie September Aecamber-, <br /> S. Number of yearlong residents: T <br /> 6. Number of residents per month, If variable: <br /> April October <br /> ....,,.. ,.,,� <br /> 'March $August __�yembar <br /> June <br /> _ <br /> February , - May I �� mber december <br /> 1 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 oranges. <br /> Facility RusineWProporty Owner �.u1� -- Date: <br /> , sig,erure <br /> W <br /> 4 <br /> 1668 E. Hazelton Avenue I Stockton, Californias 952051 T 209 468-34201 F 209 464-0138 1 www.sicehd.cam <br />