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PA2200254 <br /> SAN-:JOAQUIN Environmental Health Department <br /> __. c 0 U NT v---- <br /> Grootfiess grows here. <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: <br /> Facility Address: <br /> Street City Zip <br /> Facility Business Owner Name:^ _ Phone: <br /> Property Owner Name: _ Phone: <br /> Property Owner Address: <br /> sire©r city ZIP <br /> WATER PROVISION INFORMATION <br /> 1, Number of houses, mobile homes, or other occupied buildings served by the water well(s) Z <br /> 2. Number of employees at the facility per shift: q Number of shifts 7- — <br /> 3. Total number of employees, customers, and visitors at the facility per month, If variable: <br /> January to April Y„10 July ?_0 October •E--o <br /> February S-0 May August 7-0 November -&-0 <br /> March 1210 June (7_0 September 1-Z> December <br /> 4. Number of days that total number of customers,visitors and employees frequent the facility per month: <br /> January _ April tJufy Y October <br /> Fobrunry May _ August November <br /> March <br /> Juno septembor December <br /> 5. Number of yearlong residents: <br /> 5, Number of residents per month, if variable: <br /> January April July October .-- <br /> February May August r November <br /> March r-- 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 Buslness/Property Owner: Bate: -2 c] - 14-e361 �- <br /> Sitlnalure <br /> '1868 C. Hazelton Avenue I Stockton,California 952051 T 209 466-34201 F 209 464.0138 1 www,sJcehdxom <br />