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SAN 10 A Q U I N Environmental Health Department <br /> - COUNTY <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: Pout's House of Cactus <br /> Facility Address: 17229 East State Hwy 120 Ripon 95366 <br /> Street city zip <br /> Facility Business Owner Name: Bill, Roelyn & Brian Poot Phone:209-599-7241 <br /> Property Owner Name: Bill, Roelyn & Brian Poot Phone:209-599-7241 <br /> Property Owner Address: 17229 East State Hwy 120 Ripon 95366 <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: 3 - 4 Number of shifts: 1 <br /> 3. Total number of employees,customers,and visitors at the facility per month, if variable: <br /> January 3 April 4 July 4 October 3 <br /> February 3 May 4 August 4 November 3 <br /> March 4 June 4 September 4 December 3 <br /> /✓'� u S0-7 47-ouR tS fVE� <br /> 4. Number of days that total number of customers,visitors and employees frequent the facility per month: <br /> January 26 April 25 July 26 October 26 <br /> February 24 May 27 August 27 November 25 <br /> March 27 June 26 September 26 December 25 <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 /> Facility Business/Property Owner: Date: 06-30-23 <br /> SigrWure <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />