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' �: SAN_JOAQUIN Environmental HealtYl Department <br /> ��.�.LS&S_� �. 4'j. —COUNTY <br /> _sy Greo tness grows fiere. <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: <br /> Facility Address: <br /> Facility Business Owner Nama: S1•eB1 cf Phone: zp <br /> Property Owner Name: Phone: <br /> Property Owner Address: <br /> Sbaet Ciry ZIO <br /> WATER PROVISION INFORMATION <br /> t. Number of houses, mobile homes, or other occupied buildings served by the water well(s):� <br /> 2. Number of employees at the facility per shift: CJ Number of shifts: <br /> 3. Total number of employees, customers,and visitors at the facility per month, if variable: <br /> January S April July ovYobar <br /> FaMuary rj May .� August November ,j <br /> Marcb Juna 3aptambcr Oaenmbar <br /> 4. Number of days that total number of customers,.visitors and employees frequent the facility per month: <br /> January APHI July October <br /> February May Augual Nowmbx <br /> Maruti Juna September December <br /> 5. Number of yearlong residents: n <br /> 6. Number of residents per month, if variabl¢: <br /> January APrll JUIY October <br /> February May August November <br /> Marab Juna September Deoambar <br /> /dec/are under peva/ty of perjury that the stat¢m¢nts on this app/ication are correct to my know/edge. /t is the <br /> owner's responsibi/lty to notify this office if the water provision information o7 the facl/ity changes. <br /> Facility Business/Property Owner: Date: <br /> t 868 E. Hazelton Avenue Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />