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WATER PROVISION DECLARATION <br />Facility Business Name:�/�✓Y1 <br />Facility Address: ' 0-6 <br />Street City Zip <br />Facility -Business Owner Name: BSc:; Phone: ` <br />Property Owner -Name: 'T� e Phone: <br />Property Owner Address: <br />6.7 C-1 c <br />City <br />WATER PROVISION INFORMATION <br />Zip <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: — Number, of shifts: / <br />3. Total number of employees, customers, and visitors at the facility per month, if variable: <br />January <br />April July <br />April <br />October <br />July <br />February <br />October <br />February <br />February <br />March <br />May <br />May <br />June <br />June September <br />August <br />September <br />December <br />November <br />December <br />June <br />4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br />January <br />April July <br />April <br />October <br />July <br />February <br />May August <br />February <br />November <br />May <br />March <br />June September <br />November <br />December <br />March <br />5. Number of yearlong residents: <br />6. Number of residents per month, if variable: <br />January <br />April <br />July <br />October <br />February <br />May <br />August <br />November <br />March <br />June <br />September <br />December <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 />Facility Business/Property Owner: Date: <br />Signature <br />/,;) -1d -- '7�0_ <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />