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JUN-08-2004 17:34 P.02 <br /> a HPI JVAVUIN C-()UNITY <br /> TY <br /> WIRONMEN7AL.HFALTR DEPART11�T1✓- -T <br /> 304 l=ast Weber Avenue,3'd Floor,Stockton,CA 95202-2708 <br /> \ (209)468-3420 •Fax:(209)464-0138- Web:www.co.sau joaquin_ca.us/ehd <br /> WATER SYSTEM DECLARATION <br /> Facility Name: <br /> Facility Address- <br /> t City <br /> Facility Busine=ss Owner: odc <br /> Property Owner: yks Zi <br /> street <br /> City -p coat <br /> FACILITY IN <br /> FQRMATION <br /> 1. Number of houses, mobile homes,or other occupied buildings served by the water well(s): <br /> 2. Number of employees at the facility per shift: number of drifts- <br /> 3. Number of employees at the facility per month,if vartable: <br /> JanuaryApril ! © i July October Z, <br /> FrlytztaryMay, ! Au ust ! � iYovembtr C- <br /> March Q Jape Q September -7— ?ecetsrAtr <br /> 4- Number of days that the total number of customers,%isiturs and employees that frequent the facility <br /> exceeds 24 in each month(i.e.,25 or more•customers on.6 days in January,or 25 t/6 days): <br /> January <n I April JUN October <br /> February Q May August © November <br /> March June September December <br /> S. Number of yearlong residents: <br /> 6. Number of residents per month,if vanable: <br /> January O April <br /> July October <br /> j February Maty August Q November <br /> Mph ` June September December , <br /> WATF$,PROVISION INFORMATION <br /> Using the information listed abov-c,please ebeck the box that best describes the water provision at the facility. <br /> Q The iwll saves at least 15 comections used by yearlong LSsldenu or it regularly serves at least 25 yearlottg residents <br /> (Cortunauuty)- <br /> ❑ The well serves at least 25 of the 1aje persons(i.e.,employees,students)over six jQw the per year <br /> (NTNG-The well serves 25 or snore persons(not the stye persons i-e.customers,vistors)at least 60 days per year(Th C). <br /> (] The well serves Sme-L5 to 14 connections(i.e.,bouses,inobile homes,etc)and does not serve water to as average of <br /> K2 dividuaJs daily for mo, than 60 days out of the year(State Small). <br /> alb y �T1� ll serves leas than Eve(5)conaecti9M and togularly serves a4 or less individuals daily through out the year. <br /> Y (We)declare under penalty ofperjury that the statements on this application are correct to my(our)knowledge. <br /> It is the owner's responsibility to notify this office ifthe operation of the facility changes to the extent it now <br /> meets a different definition of a public war ate dicat n this f ,y <br /> FacilityBusinessfPr Owner Date v <br /> ��y <br /> S � <br /> EHO 46-e2-008 eater System Dcclarat M <br /> 2'17�200a <br /> TnTAI P-AS <br />