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k{ SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT +r• 1868 East Hazelton Avenue , Stockton, CA 95205-6232 �' +' Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www. sjgov. org/ehd listhi WATER SYSTEM DECLARATION u Facility Name: Odyssey Landscaping Company , Inc . �i Facility Address : 5400 W . Highway 12 , Lodi , CA 95242 Street city Zip Code !! Facility Business Owner: Martin Gates Property Owner: Gates Family Trust Street City Zip Code FACILITY INFORMATION 1 . Number of houses, mobile homes , or other occupied buildings served by the water well (s): y 2. Number of employees at the facility per shift: 17 Number of shifts: 0 w i 3. Number of employees at the facility per month , if variable: January April July October i February May August November I March June September December 4. Number of days that the total number of customers, visitors and employees that frequent the facility exceeds 24 in each month (i. e. , 25 or more customers on 6 days in January, or 25 +16 days) : January April July October February May August November March June September December 5 . Number of yearlong residents: 0 6. Number of residents per month , if variable: JanuaryApril July October February May August November March June September December WATER PROVISION INFORMATION Using the information listed above, please check the box that best describes the water provision at the facility: ❑ The well serves at least 15 connections used by yearlong residents or it regularly serves at least 25 yearlong residents (Community) . ❑ The well serves at least 25 of the same persons (i.e. , employees, students) over six months per year (NTNC). ❑ The well serves 25 or more persons (not the same persons, i.e. , customers, visitors) at least 60 days per year (TNC) . ❑ The well serves five (5) to 14 connections (i .e. , houses, mobile homes, etc) and does not serve water to an average of 25 individuals daily for more than 60 days out of the year (State Small). I The well serves less than five (5) connections and regularly serves 24 or less individuals daily through out the year. I (We) declare under penalty of perjury that the statements on this application are correct to my (our) knowledge. It is the owner's responsibility to notify this office if the operation of the facility changes to the extent it now meets a different definition of a public water system then indicated on this form. Facility Business/Property Owner: _ 9ate : (f le�/� Signature Martin Gates EHD 48-08 WATER SYSTEM DECLARATION 4130112