Laserfiche WebLink
�`zT f rJ <br /> WATER SYSTEM DECLARATION <br /> FACILITY ADDRESS: 'rYIn l " &=" �?l S �j/G/� td/V <br /> STREET U CITY ' ZIP <br /> FACILITY BUSINESS OWNER: v 11A40-AH -Df4G fkn51cL( <br /> NAME <br /> PROPERTY OWNER: I w1041�( Dok SIS <br /> NAME <br /> Please complete the following: <br /> Number of houses, mobile homes, or other occupied buildings served by the water well(s): <br /> v Number of employees at the facility per shift:_ 5 Number of shifts: <br /> umber of employees at the facility per month, if variable: <br /> JAN S FEB- 5 MAR 5 APR S MAY 5 JUN S <br /> JUL _ AUG S SEP 5 OCT S NOV_,f� DEC S <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+/6 days) N� <br /> JAN I'� FEB I-XlO MARJ-- ZG� APR 1'a"" MAY_g_��00 JUN_ <br /> JUL I"ZZ)O AUG SEP �' OCII �IT� NOV a'��U DEC-, L <br /> Number of yearlong residents: �— <br /> Umber 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 /> ❑0 The well serves at least 15 connections used by yearlong residents <br /> Or it regularly serves at least 25 yearlong residents. (Community) <br /> 00 The well serves at least 25 of the same persons(i.e. employees, students)over six months per year <br /> (NTNC) <br /> ❑0 The well serves 25 or more persons(not the same persons, i.e. customers,visitors)at least 60 days per <br /> year. (TNC) <br /> 1710 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 s es 24 or less individuals daily throughout the <br /> year. (Private water system). <br /> (We) declare under penalty of perjury that the statements n t s application are correct to my(our)knowledge. <br /> It is the owners responsibility to notify this office if the oper ion f the facility changes t the extent it now meets a <br /> different definition of a public waters ste the indi ated//o�,n thi orm. <br /> �ACILITY BUSINESS/ PROPERTY OWNER: <br /> A URE E <br />