Laserfiche WebLink
SAN OAQU <br /> Environmental Health Department <br /> COUNTY <br /> Greatness grows here . <br /> WATER PROVISION DECLARATION <br /> Facility Business Name : �� 114V <br /> Facility Address : v ' 0 k4 fi .ONa - © � �o & <br /> Street City Zip <br /> Facility Business Owner Name : �} ��Q�_� I Lo u j 1' joLl Phone : <br /> Property Owner Name : � q � t V �( „ �! � , �� ��b Phone : 9 a � _ -3 57 <br /> Property Owner Address : !3 �,,� r ,� � hip � 6 < � �J � � f� � q5 207 <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 h <br /> FebruaryMay August November <br /> 16 <br /> March June 44September 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 ol CA August November <br /> March June September December <br /> wor MEF <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 1 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 : OS Ll 07 7 <br /> ignature <br /> 1868 E . Hazelton Avenue Stockton , California 95205 1 T 209 468 - 3420 F 209 464 - 0138 1 www . sjcehd . com <br />