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SAN J OAQ U I N Environmental Health Department <br /> C O U 'ti T Y---- <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: <br /> Facility Address: (Qlr�of'�ll� �� i. p„ <br /> Street City Zip <br /> Facility Business Owner Name: �,q) 0& L 1 Phone: <br /> Property Owner Name: 4S jeo 1, GL'c Phone: �� � � _'�89 <br /> Property Owner Address: �,a 2 rte• ' tet �� – -- - � g���(l�l <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: _1110" <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January April r July October <br /> February May August 2 November A- <br /> March I I June �� September -4 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 /> February May August November <br /> March June September December <br /> 5. Number of yearlong residents:_TV—J <br /> 6. Number of residents per month, if variable: <br /> January April July October <br /> FebruaryAugust 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: A(? Date: _ <br /> Signature <br /> f or- <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />