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WATER SYSTEM DECLARATION <br /> FACILITY ADDRESS: ciTv ziP <br /> STREET <br /> FACILITY BUSINESS OWNER: NAME <br /> PROPERTY OWNER: NAME <br /> Please complete the following: <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: 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 <br /> OCT NOV DEC <br /> Number of customers at the facility per month, if variable: <br /> JAN FEBMAR APR MAY JUN <br /> JUL AUG SEP OCT NOV DEC <br /> Number of yearlong residents: <br /> Number of residents per month, if variable: <br /> JAN FEB <br /> MAR APR MAY JUN <br /> JUL AUG SEP <br /> OCT NOV DEC <br /> Using the information listed above, please check the box that best describes the water provision at the facility. <br /> El F1 The well serves at least 15 connections used by yearlong residents <br /> Or it regularly serves at least 25 yearlong residents. (Community) <br /> 00 The well serves at least 25 of the same persons (i.e. employees, students)over six months per year <br /> (NTNG) <br /> 00 The well serves 25 or more persons (not the same persons, i.e. customers, visitors) at least 60 days per <br /> year. (TNG) <br /> s (i.e. houses, mobile homes, etc.) and does not serve water to an <br /> ❑0 The well serves five to 14 connection <br /> average of 25 individuals daily for more than 60 days out of the year. (State Small) <br /> EI F1 The well serves less than 5 connections and regularly serves 24 or less individuals daily throughout the <br /> year. <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 OWNER: SIGNATURE DATE <br /> PROPERTY OWNER: SIGNATURE DATE <br />