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F V <br /> WATER SYSTEM DECLARATION f <br /> FACILITY.ADDRESS: Sss CITY Zip <br /> —TT—FiEET t f <br /> FACi'D T Y BUS i1cSS_0WNER. NAME <br /> PROPERTY OWNER: <br /> NAME <br /> Please complete the following: <br /> Number of houses, mobile homes, or other occupied buildings served by the water weil(s). <br /> Number of errlployees at the facility per shift: Z Number of shifts-. <br /> Number of employees at the facility per month, if varlabie. <br /> JAN 2 FEB 2 MAR Z APR Z.- MAY Z JUN—,?— <br /> JUL___?, <br /> AUG SEP Z OCT__�� NOV _ DEC��_ <br /> Number of days that the total number of customers, visitors and employees that frequent the facility exceeds 24 <br /> in each month: <br /> (i.e. 25 or more customers on 6 days in January, or 25+16 days)t <br /> JAN FEB_ __MAR __ APR �7 MAY , __ JUN .f <br /> JUL_. AUGSEP---�/ OCT NOV DEC_ _ <br /> Number of yearlong residents: <br /> Number of residents per month, if variable: <br /> JAN FEB !1/ 64 MAR APRMAY_ JUN <br /> JULAL/ _._._ AUG SEP OCT NOVDEC <br /> X <br /> Using the information listed above, please check the box that best describes the water provision at the facility. <br /> ❑ 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 /> ❑ 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 throughout the <br /> j year. (Private water system). <br /> penalty of perjury that the statemen <br /> (We) declare under. ts.on this application are correct to my(our) knowledge. <br /> It is the owner's responsibility to'notify this office if the operation t e facilit changes to the extent it now meets a <br /> different definition of a public water yst then indi 3ted on this form. <br /> FACILITY BUSINESS/ PROPERTY OWNE I TURE D4 E <br /> t <br />