Laserfiche WebLink
.�_ <br />SAN J OAQ U I N Environmental Health Department <br />_._......__CGU ^` T Y---_ <br />cc ._.....:. F <br />•�:�.r>+,� Grectness qrows <br />WATER PROVISION DECLARATION <br />r� n <br />Facility Business Name: c f A �)11, <br />Facility Address: 10,iry , VW q1 V-, g,. .V?*-fd pj -1 !�'%-4f), <br />Street City Zip <br />Facility Business Owner Name:d�� ig, _ L e_30 164,4 r 1g (y Phone:��r���� �8 <br />Property Owner Name: A�— Phone:Q <br />Property Ocrner Address: 3,02 ' s-4, � TVStreet City Zip <br />WATER PROVISION INFORMATION <br />1- Number of houses, mobile homes, or other occupied buildings served by the water well(s):A*�Ye <br />2. Number of employees at the facility per shift: Number of shifts: ertiln— <br />3. Total number of employees, customers, and visitors at the facility per month, if variable: <br />January <br />April <br />, July October <br />October <br />February <br />May <br />August November <br />November <br />March <br />June <br />September December <br />December <br />IF <br />FA <br />4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br />January <br />April <br />July <br />October <br />February <br />May <br />August <br />November <br />March <br />June <br />September <br />December <br />5. Number of yearlong residents: Two <br />6. Number of residents per month, if variable: <br />January April July October <br />February 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: A(?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 />