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SANAAQUIN Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: flrmO <br /> Facility Address: -J <br /> c+tr n <br /> Facility Business Owner Name: • O Phone: O <br /> Property Owner Name: Phone: <br /> Property Owner Address: <br /> SI 5C*Y ZP <br /> WATER PROVISION INFORMATION S <br /> 1. Number of houses, mobile homes, orffM pled buildings served by the water well(s):—A— <br /> 2. Number of employees at the facility per shift: Number of shifts:_ 1 <br /> 3. Total number of employees,customers,and visitors at the facility per month, if variable: <br /> jw� April July October <br /> February May August November <br /> March June sepMnrber December <br /> 4. Number of days that total number of customers,visitors and employees frequent the facility per month: <br /> Jarxiary _ July 177 October <br /> Febnmy August November <br /> Mach June Sep/errrber December <br /> 5. Number of yearlong residents: <br /> 6. Number of residents per month, if variable: <br /> Jumery April 4 July October <br /> Februry May August November — <br /> March June September December <br /> l declare under penalty of perjury that the statements on this application are correct to my knowledge. It is the <br /> owners responsibility to notify this o •ce if the water provision information of the facility changes. <br /> Facility Business/Property Owner: Date: 2 <br /> sgnau,re <br /> 1868 E. Hazeflon Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />