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aAN JOAmnm, com-5 ri EwiRONMENTAL HEALTH DEPARTMENT 70 = �,- 1 1868 fast I-iazeiton Avenue, Stockton, CA 95205-6232 {•- '' °" sIGp cne: (209) 468-3420 Fa,;: (209) 4.64-0138 Web:wwvv.sjgov.crglehd VIV R, SYS a FH DEC U-k ATMM Facility Name: Facility Address: 2 i820{V, �`'l �5h� &A2n 95::—ZI Street d City Zip Code Facility Business Owner: M a Property Owner: (C-) kc ' ` O LA tS 2 f - Street —,City Zip Code FALUTY INFORMA IE M 1. Number of houses, rnobile homes, or other occupied buildings served by the water well(s): 2. Number of employees at the facility per shift: �)-_ Number of shifts: — 3. Number o;ern[oloyees at the facility per month, if variable: January April July October February May August November March June September December 4. Number of days that the total number of cus'fomeys, ;Asi tors and emplmyeas that frequent the facility exceeois 2E1. in each month (i,e., 25 or more customers on 6 days in January, or 25 x-16 days)- January April y July October =C February May Ll August November March y June September December 5. Number of yeaftrbg ras;idents: 6. Number of residents per rrnont-la, if variable: January April July octabar February May August November March June September December WATER PROVISM WORMATION Using the information listed above, please check the bo,: that best describes the water provision at the facility: ❑ The well serves at least 15 connections used by yearlong residents or it regularly serves at least 25 yearlong residents (Community). ❑ The well serves at least 25 of the same persons (i.e., employees, students) over sig;months per year(NTNC). ❑ The well serves 25 or more persons (not the same [persons, i.e., customers, visitors) at least 60 days per year(TNC). ❑ The well serves five 5 to J4 connections (Le., houses, mobile homes, etc) and does not serve water to an average of 25 individuals daily for more than 60 days out of the year(State Small). ❑ The well serves less than five(5)connections and regularly serves 24 or Fess individuals daily through out the year. I (We) declare under penalty of perjury that the statements on this application are correct to my (our) knowledge. It is the owner's responsibility to notify this office if the operation of the facility changes to the extent it now meets a different definition of a public water system then indicated on this form. Facility Business/Property Owner: fix/ �!! Date: �Signatur� EHD 46-08 WATER SYSTEM DECLARATION 4134112