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SAN JOAQUIN Environmental Health Department <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: River Oak-Orchards <br /> Facility Address: c4839 Hutchinson Road <br /> — trb0t City Zip <br /> Facility Business Owner Name: Chris Van Groningen Phone: (2139} <br /> 652=3969 — <br /> Property Owner Name: Chris and Laurie Van Groningen Phone: (209) 652-3969 <br /> Property Owner Address: 9851 Hutchinson Road Manteca CA 95337 <br /> City 4 <br /> WATER PROVISION INFORMATION <br /> 1. Number of houses, mobile homes, or other occupied buildings served by the water well(s):,1 <br /> 2. Number of employees at the facility per Shift: 23 Number of shifts: <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> .. ..........._� '­. ..— <br /> January f 35 April I 35 July 23, October I 55 <br /> February 315 May 35 August 23 November so <br /> Match 35 .lune S�Pptemborj December "=6 <br /> ........... <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> 21 July 21 October <br /> January21 .. . ........ <br /> 21 May 21 August 21 November 21 <br /> Una ber cember 21 <br /> February <br /> March 21 23 <br /> 5. Number of yearlong residents: 5 <br /> 6. Number of residents per month, if variable: <br /> January April October 5 <br /> _.-6 <br /> J --- -------- <br /> 5 <br /> February May �_s August November <br /> .. ........... <br /> March 5 June $ 5 <br /> September <br /> I declare under penalty of perjury that the statements on this application are correct to my knov."Iedge. It is the <br /> owner's responsibility to notify this office if the water provision information of the facility changes, <br /> Facfl!ty Business/Prope:­ty Owner; Date: <br /> f. ............... <br /> '186,8 F_ Hazelton Avenue 1 Stockton,Cafifornia;95205 T 208 468-3420 1 F 209,464-01.38 i www.slcenic.com <br />