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WATER PROVISION DECLARATION <br /> Facility Business Name: <br /> Facility Address: 7 7 V CC <br /> Street City Zip <br /> Phone: &�'Y ctw 3 z3 7 <br /> Facility Business Owner Name: t � �- ;; j / <br /> Property Owner Name: 1 koi/ , Phone: 3-777 <br /> Property Owner Address: 11)jI JAI. ue, <br /> S eet 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: <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January "" April July October ` <br /> February May August i/ November <br /> March June September / December ' <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January ) April July '. October <br /> February May August � November <br /> March June '' September ;':-' December <br /> 5. Number of yearlong residents: <br /> 6. Number of residents per month, if variable: <br /> January April July /r' October <br /> February ' May August f' 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 /> Facility Business/Property Owner: ,e' - � f✓- �--- %'�__ Date: <br /> 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 www.sjcehd.com <br />