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`:. _ 71 14 03 11:41a <br />07/11/03 14;44 <br />FACILIT`! <br />I <br />Cc3"",qti;ino 7071.1254 p. 2 <br />1 --i �v�f,Jjl'J Poi <br />P.AYM6.' 'GREER CONSTRUCTION 4 7079441254 <br />I <br />WATER SYSTEM DECLARATION <br />Z,P <br />!�rv��✓I��h <br />FACILITY BUSINESS OWNER. Mw <br />UR <br />!I <br />PROPERTY OWNER- Cose,M `+� 0 <br />li NAME <br />Please complete the following' <br />I Number of houses, mobile ho i1jes, or other occupied buildings Served <br />by the water wetl(4 <br />2 Number of employees at the facility per shifl:� <br />Number of shifts: <br />2 Number of employees at the f cilKY per month, if variable: <br />JAfJ�_ FEB � �I MAR APR ZL�. MAY' JIiN z <br />2�INOV �' OEC_ <br />JU1 AIJG SEPOCT—f—; <br />4 Number of yearlong resivallib� <br />5 Number of residents per month, if variable; MAY <br />i _ O dtJNV <br />Jp,N FC:B��� MAR APR <br />JUL_ <br />AUG_ SEP– OCT_ � NOV _., DEC <br />_ - ii <br />Using the information listed above, please checK the box that best describes the +mater provision at ttte facility <br />CIO The well serves at least 15 Connections used by yearlong r4sidsrets <br />Or it regularly serves at leash 2S yearlong reser„ dents. (Com+nunhy) <br />no The well serves at least 25 olf the same persons (i.e. employees, students) over six Months p year <br />(NTNC) <br />Customers, visitors} at least 60 days Per <br />00 The well serves 75 or more persons not the same arsons, i.e. <br />year. (TNC) <br />❑q -rm well serve$ rw duffs day ria mar than than so days out ofthe Year. (State a Sm )and s r0t serve water to an <br />average of 25 lad i. <br />serves 24 or less individuais daily though out the <br />'rhe well serves lan'then 5.co"Mjtions and regularly <br />year. <br />to and true_ <br />l-h4reby declare Ithe he above Information is a <br />FACILIV W, SINES OWNER' EK4wAN T <br />PROPERTY -OWNER: , PATE <br />sl G 1l1~ <br />, <br />