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002753 <br /> y/�pO�D WATER SYSTEM DECLARATION <br /> FACILITY ADDRESS H G 7-Add'-I ?e) / sy,4,on & '/ S 2 2 G _ <br /> STREET r CITY ZIP <br /> FACILITY BUSINESS OWNER'&14 I t) C r�y <br /> NAME t <br /> PROPERTY OWNER: f <br /> NAME <br /> Please complete the following <br /> Number of houses, mobile homes, or other occupied buildings served by the water well(s)—v __ <br /> Number of employees at the facility per shift Ilk <br /> Number of shifts: _ <br /> Number of employees at the facility per month, If variable- <br /> JAN— FEB MAR APR MAY JUN <br /> JUL AUG SEP OCT NOV 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 Janupry. or 25+/6 days) <br /> JAN Z FEB_ Z MAR. Z- APR 2 MAY JUN <br /> JUL 7i AUG 2 SEP_�� OCT Z NOV _ DEC _ <br /> Number of yearlong residents 7J/6/D � <br /> Number 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 /> ❑ The well serves at least 15 connections used by yearlong residents <br /> Or It regularly serves at least 25 yearlong resfdents. (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' <br /> TSIGNATUR�—RE QATE --� <br />