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1 � <br /> SAN J O A O U I N Environmental Health Department <br /> COUNTY <br /> Grentne5s ryrnvrs herr?. <br /> WATER PROVISION DECLAMATION <br /> Facility Business Name: Pleasant Valliey I~armss.INC DBA Jenkins Poultry Farms <br /> Facility Address: 30.6.3.6 E. Carter Road Farmington,CA 95230 <br /> Elmet City ZipFacility Business Owner Name: Richard Jenkins Phone: 209-$86-'1000 <br /> Property Owner Name: Richard Jenkins — Phone: 209-575-0619 <br /> Property Owner Address: 1454 Ladd Road,_Madesto, CA 953_56_ <br /> --- - — streel City 2'p- <br /> WATER PROVISION INFORMATION <br /> 1. Number of houses, mobile homes, or other occupied buildings served by the water well($): 5 <br /> 2. Number of employees at the facility per shift: 2616 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 /> Februaty May August Novamber <br /> March Juno September December <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January 31 April 130 July 31 October 31 <br /> February 2s May 31 August 31 November 30 <br /> March 31 June 30 Seplernber 30 December 131 <br /> 5. Number of yearlong residents: 4 <br /> 6. Number of residents per month, if variable: _ <br /> January April July October <br /> February May August November <br /> March_ June _-_ i September December <br /> !declare under penally of perjury that the statements on this application are correct to my knowledge. !tis the <br /> owner's responsibility to notify this office if the water provision information of the facility Changes. <br /> Facility Business/Property Owner: Date: Z. <br /> Signature <br /> 1868 F. Hazelton Avenue I Stockton, California 952061 T 209 468-3420 1 F 209 464-0138 1 www.sjcand.com <br />