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SAN J O A Q U I N Environmental Health Department <br /> C-CDu lel rv - <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: 1Q` <br /> Facility Address: 2 (� 1� z�_. l _ - <br /> -�b�� Straw, (a"ly ! Zip <br /> Facility Business Owner Name: - I� Phone: <br /> Property Owner Name: L _ !Ju/}l./pu�,�/�. Phone:_ <br /> Property Owner Address: I&Ii/tom /�� S`l,jr <br /> Straot Ci Zip <br /> WATER PROVISION INFORMATION l <br /> 1. Number of houses, mobile homes, or other occupied buildings served by the water well(s): t� <br /> 2. Number of employees at the facility per shift: Ly//�_ Number of shifts:_[`4 <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> Januar _ April _ I July _ I October <br /> Fabruar Ma Au ust 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 I I 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 /> J anua rY - _ April July - I October <br /> February May August November <br /> March Juna S.pl—b— 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 <br /> J this office if1the water provision information of the facility changes- <br /> Facility Business/Property Owner`yfFl ,A'_L,,,_,�4w�.. r-�����.Jr`_ mate: _c*::',I�_-14-1-: .�'-L_'� <br /> T SIg alu <br /> 1868 E. Hazelton Avenue I Stockton, Califonriia 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.corn <br />