Laserfiche WebLink
SAN 10AQUi., <br />—COUNTY— <br />Environment.j Health Department <br />WATER PROVISION DECLARATION <br />Facility Business Name: DOES NOT APPLY <br />Facility Address: APN.- 003-100-330 TBD <br />Street <br />Facility Business Owner Name: <br />Property Owner Name: Bart Roberston <br />Zip <br />Phone: <br />Phone: 209.329-9946 <br />Property Owner Address: TBD <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):1 <br />2. Number of employees at the facility per shift: DNA Number of shifts: DNA <br />3. Total number of emDlovees, customers, and visitors at the facilitv oer month. if variable: <br />January April July October <br />February May August November <br />March June September December <br />4. Number of days that total number of customers, visitors and emplovees frequent the facilitv per month: <br />January April July October <br />February May August November <br />March June September December <br />5. Number of yearlong residents: 2 <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 this office if the water provision information of the facility changes. <br />Q <br />Facility Business/Property Owner: Date: 8/11/22 <br />Signature <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />