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o S uSAN JOAQUIN COUNTY <br /> GZ <br /> ENcONMENTAL HEALTH DEPARTM—NT <br /> 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br /> 100A <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> WATER SYSTEM DECLARATION <br /> Facility Name: <br /> Facility Address: <br /> Street City Zip Code <br /> Facility Business Owner: <br /> Property Owner: <br /> Street City Zip Code <br /> FACILITY 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. Number of employees 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 the total number of customers,visitors and employees that frequent the facility <br /> exceeds 24 in each month(i.e.,25 or more customers on 6 days in January,or 25 +/6 days): <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 /> WATER PROVISION INFORMATION <br /> Using the information listed above,please check the box that best describes the water provision at the facility: <br /> ❑ The well serves at least 15 connections used by yearlong residents or it regularly serves at least 25 yearlong residents <br /> (Community). <br /> ❑ The well serves at least 25 of the same persons(i.e.,employees,students)over six months per year(NTNC). <br /> ❑ The well serves 25 or more persons(not the same persons,i.e.,customers,vistors)at least 60 days per year(TNC). <br /> ❑ The well serves five(5)to 14 connections(i.e.,houses,mobile homes,etc)and does not serve water to an average of <br /> 25 individuals daily for more than 60 days out of the year(State Small). <br /> ❑ The well serves less than five(5)connections and regularly serves 24 or less individuals daily through out the year. <br /> I(We)declare under penalty of perjury that the statements on this application are correct to my(our)knowledge. <br /> It is the owner's responsibility to notify this office if the operation of the facility changes to the extent it now <br /> meets a different definition of a public water system then indicated on this form. <br /> Facility Business/Property Owner: Date: <br /> Signature <br /> EHD 46-02-008 Water System Declaration <br /> 2/17/2004 <br />