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SAN JOAQUIN Environmental Health Department <br /> COUNTY <br /> WATER PROVISION DECLARATION <br /> p ---) - <br /> Facility Business Name: -�' <br /> Facility Address: 15 1') <br /> Street City zip <br /> Facility Business Owner Name: 21 41� (� Phone: u;; <br /> Phone: <br /> Property Owner Name: <br /> Property Owner Address: <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: 1I <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January 11 K:a) April Z ¢ July October <br /> February May August November <br /> March ; June June September <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January !J April 0 July October <br /> February e; <br /> May August November <br /> )l <br /> March k June "t 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 /> 0 <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: Date: <br /> Signature <br /> 1868 E. Hazelton Avenue � Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br />