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SAN J 0 A Q U I <br /> Envi ronmentar .iealth Department <br /> COUNTY <br /> "220 ® 025 <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: <br /> Facility Address: <br /> Street City Zip <br /> Facility Business Owner Name: -� Sc Phone: <br /> Property Owner Name: S�^MJ — Phone: <br /> Property Owner Address: <br /> reet City Zip <br /> WATER PROVISION INFORMATION <br /> 1. Number of houses, mobile homes, or other occupied buildings served by the water well(s): 3 <br /> 2. Number of employees at the facility per shift: 10 Number of shifts: <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January L1 (j April July October <br /> February May August November <br /> March June September December c � <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January 3 i April 3.D July 3I October 3 <br /> February .2-g May 31 August .j November `j <br /> March 31 June 3September 3 December 3 <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 /> 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 t "s ffice if the water provision information of the facility changes. <br /> Facility Business/Property Owner: �i' Date: <br /> Signat <br /> 1868 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />