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FD-)EC EffE J <br /> MAK 2 II 2DD8 <br /> ENVIRONMENT HEALTH <br /> WATER SYSTEM DECLARATION °ERMIT/SERVICES <br /> FACILITY ADDRESS: ea ) /4 �Jy J a /,U p2 � p <br /> STREET CITY IP <br /> FACILITY BUSINESS OWNER: 12C'Ie&1464-0 1nl�ry�124 <br /> NAME <br /> PROPERTY OWNER: �, o'se to 14 13 C tP6�8 &I-o <br /> NAME _ <br /> Please complete the following: SEfZVr--j .(3ARK'�t—STD/2.46 /� S"TTlY��Iuori'1 <br /> Q4 ��IteS <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: <br /> Number of employees at the facility per month, if variable: -* / eQ, kf- <br /> JAN _ FEB a MAR _ APR MAY JUN <br /> JUL AUG 3 9 SEP 3 46 OCT 2 ''It- NOV 'd. DEC 1 <br /> Number of days that the total number of customers,visitors and employees that frequent the facility exceeds 24 <br /> in each month: Oee- <br /> (i.e. 25 or more customers on 6 days in January, or 25+/6 days) <br /> JAN� FEB MAR _ APR_ / MAY _ JUN_ <br /> JUL AUG 2• SEP OCT NOV -/' DEC <br /> Number of yearlong residents: <br /> Number of residQnts per month,� Mvariable, <br /> JAN--`'A+� FEB MAR APR MAY JUN�� <br /> JUL__O_ AUG _SEPI _ OCT _ NOV C DEC <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 /> 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�t '312616 .0.1 <br /> 0 SIGNATURE DATE <br />