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r <br /> 10/61/263 g9:08 X094683433 F1FIN I-LUUK rF�u� dz <br /> WATER SYSTEM <br /> DECLARATION r <br /> FACILITY ADDRESS: 231 O O 'J� SSG+'t fQ0 ,r Qw q( `7 <br /> $TRCCT ,,�l,� CITY ZIP <br /> FACILITY BUSINESS OWNER:�f;r"UP l- IA"fn-Vcq,�'' - y'lkj�a� T K <br /> NAME <br /> PROPERTY OWNER: Zee Ile 1,ws <br /> NAME <br /> Please complete the following: <br /> Number of houses, mobile homes,or other occupied buildings served by the water well(s): <br /> Number of employees at the facility per shift `0 Number of shifts: <br /> Number of employees at the facility per month, if variable: <br /> JAN FEB MAR APR MAY JUN <br /> JUL_ d AUG _SEP tP QCT_ NOV_ QEC_L— <br /> Number of days that the total number of customers,visitors and employees that frequent the facility exceeds 24 <br /> In each month. <br /> (i.e. 25 or more customers on 6 days in January, or 25+/6 days) <br /> JAN FEEB—MAR __ ____ APR­—�—' MAY , JUN_ _ <br /> JUL _ AUG SFP OCT NDV DEC <br /> Number of yearlong residents' <br /> Number of residents per month, if variable: <br /> JAN_ FEB MAR APR MAY JUN <br /> JUL AU(: SEP OCT NOV DEC <br /> Using the Infonratlon listed above, please check the box that best describes the water provision at the facility. <br /> Q❑ The well serves at least 15 connections used by yearlong LqgLcLtis <br /> Or it regularly serves at least 25 yearlong residents. (Community) <br /> LID The well serves at least 25 of the same persons (i.e. employees,students)over six months per year <br /> (NTNG) <br /> C71 The well serves 25 or more persons(not the same persons, i.e. customers,visitors)at least 60 days per <br /> year. (TNC) <br /> 00 The well serves fixe to"!4 connections (i.e, houses, mobile homes, etc.)and does not serve water to an <br /> average of 25 Individuals daily for more than 60 days out of the year. (State Small) <br /> Mel The well serves less than 5 connections and regularly serves 24 or less individuals daily throughout the <br /> year_ (Private water system). <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 rasponslblI ty to notify this office If the operation of the facility changes to tele extent It now meets a <br /> different definition of a p&ic water sy, t then ' ic%kt9d on this form. <br /> FACILITY BUSINESS/PROPERTY OWNER: �d A TJ <br /> 313NATURE DATE <br />