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WATER SYSTEM DECLARATION <br /> FACILITY ADDRESS: Hkil / 1 OIYS LyQ <br /> STREET CITY ZIP <br /> FACILITY BUSINESS OWNER: 121foels-i1GL-1 In1:171,1El2U <br /> NAME <br /> PROPERTY OWNER: C1 03e& -{ 8 tFte6-8 OLD <br /> NAME _ <br /> Please complete the following: <br /> Qa�tia�ts <br /> Number of houses, mobile homes, or other occupied buildings served by the water well(s): <br /> Number of employees at the facility per shift: a Number of shifts:_1_ <br /> Number of employees at the facility per month, if variable: ,4� / 4pe„,- 7- <br /> JAN ° _ FEB 2 MAR_ _ APRMAY JUN _ <br /> JUL AI K--3. SEP--- OCT NOV a 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+/6 days) /( O� �La ^ / 00 <br /> JAN <br /> __9��FEB _MAR -_ APR___!Y_ MAY _ JUN_/ _ N <br /> JUL < AUG_ J�j _SEPY_ OCTA NOV_ DEC_ <br /> Number of yearlong residents: <br /> m <br /> Number of resiper month, variable: <br /> JAN FEB MAR 0 APR MAY JUN <br /> JUL _ AUG_SEP 10 OCT NOV_ (� DEC <br /> Using the information listed above, please check the box that best describes the water provision at the facility. N <br /> O The well serves at least 15 connections used by yearlong residents Q <br /> Or it regularly serves at least 25 yearlong residents. (Community) G <br /> ❑ The well serves at least 25 of the same persons (i.e. employees, students)over six months per year <br /> (NTNG) <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 /> year. (Private water system). <br /> I (We)declare under penalty of perjury that the statements on this application are correct to my(our)knowledge. <br /> It is the owner's responsibility to notify this office if the operation of the facility changes to the extent it now meets a <br /> different definition of a public water system then indicated on this form. <br /> FACILITY BUSINESS/PROPERTY OWNER 10, f�� 3 /2 4f® p <br /> 0 SIGNRTURE DATE <br />