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SAN JOAQUIN Environmental Health Department <br /> COUNTY - - - - -- - <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 : , 4� � , � Phone : <br /> Property Owner Address : <br /> Street ciry 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 : q114 <br /> 3 . Total number of employees , customers , and visitors at the facility per month , if variable : - JV, <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 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 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 : � � , � , � � _- r Date : rZa 1 ' � <br /> Sigi aturb 4 <br /> F <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 www . sicehd . com <br />