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WATER SYSTEM DECLARATION F <br /> j FACILITY ADDRESS: <br /> STREET CITY ZIP <br /> FACILITY BUSINESS OWNER: <br /> NAM <br /> PROPERTY OWNER: <br /> NAME <br /> Please complete the following: <br /> 1 Number of houses, mobile homes, or other occupied buildi ings served <br /> by the water well(s): 2- <br /> 2 <br /> 2 Number of employees at the facility per shift: d Number of shifts: <br /> 2 Number of employees at the facility per month, if variable: <br /> JAN_ FEB_0 MAR _ APR_ _ MAY JUN _ <br /> JUL AUG Z SEP 7 OCT—__Z- NOV--_Q�_ DEC <br /> 4 Number of yearlong residents: <br /> d <br /> 5 Number of residents per month, if variable: <br /> JAN FEB MAR APR MAY JUN <br /> JUL AUG SEP OCT NOV DEC <br /> Using the information listed above, please check the box that best describes the water provision at the facility. <br /> El The well serves at least 15 connections used by yearlong residents <br /> Or it regularly serves at least 25 yearlong residents. (Community) <br /> © The well serves at least 25 of the same persons (i.e. employees,�students)over six months per year <br /> (NTNC) <br /> El The well serves 25 or more persons (not the.same persons, i.e. customers, visitors)at least 60 days per <br /> year. (TNC) <br /> The well serves five to 14 connections(i.e. houses, mobile homes, etc.)and does not serve water to an <br /> average of 25 individuals daily for more than 60 days out of the year. (State Small) <br /> The well serves less than 5 connections and regularly serves 24 or less individuals daily though out the <br /> year. <br /> hereby declare that the abov of rmation is accurate and true. <br /> _�._. <br /> FACILITY BUSINESS OWNER: <br /> DATE <br /> PROPERTY.OWNER: <br /> S1 DATE <br /> n <br />