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SAN J OAQ U 1 N Environmental Health Department <br /> COUNTY <br /> G <br /> OU NTY-- <br /> G <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: <br /> Facility Address: <br /> Street City Zip <br /> Facility Business Owner Name: / Phone: <br /> Property Owner Nam �.Je: _ 0-5f- ,,��/0• (�� `UZ Phone: Jif ;Z 7/- <br /> Property Owner Address Pglol el ,eve o�Z�� L ,�)e)9 <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:_5 _ Number of shifts: <br /> 3. Total number of employees, customers, and visitors at the facility per month, if variable: <br /> January April July October <br /> February May August November <br /> March June September December <br /> 4. -N-umber of days that total number of customers, visitors and employees frequent the facility per month: <br /> January ZD April zV July October J fJ <br /> February 2-D May ;? August 20 November 2 <br /> March 7,bJune 2 p September 2_L2 December 7,1,S) <br /> 5. Number of yearlong residents: 1 <br /> 6. Number of residents per month, if variable: <br /> January April July October <br /> February May August November <br /> March June September 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 /> Azt� Z�xl <br /> Facility Business/Property Owner: __ Date: CJ <br /> at� <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br />