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SAN 10AQVeiv Environmentai Health Department <br /> COUNTY---- <br /> WATER <br /> OUNTY----1lil/ATER PROVISION DECLARATION <br /> Facility Business Name: <br /> Facility Address: 16201 N. Thretheway Lodi 95240 <br /> Street City Zip <br /> Facility Business Owner Name: Bill Cook Phone: (209) 610-9973 <br /> Property Owner Name: BIII Cook Phone: (209) 610-9973 <br /> Property Owner Address: 16201 N. Thretheway Lodi 95240 <br /> Street City Zip <br /> WATER PROVISION INFORMATION <br /> 1. 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: 2 Number of shifts: 1 <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January 42 April 42 July 42 October 42 <br /> February 42 May 42 August 42 November 42 <br /> March 42 June 42 September 42 December 42 <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January 16 April 16 July 16 October 16 <br /> February 16 May 16 August 16 November 16 <br /> March 16 June 16 September 16 December 16 <br /> 5. Number of yearlong residents: 2 <br /> 6. Number of residents per month, if variable: <br /> January 2 April 2 July 2 October 2 <br /> February 2 May 2 August 2 November 2 <br /> March 2 June 2 September 2 December 2 <br /> I declare under penalty of perjury that the statements on this application are correct to my knowledge. It is the <br /> owner's responsibility to notify this office if the water provision information of the facility changes. <br /> 1 <br /> Facility Business/Property Owner: Z , ' Date: <br /> Signat e <br /> 1868 E. 1-iazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />