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0""`:��, SANJOAQUIN <br />�_rcivr'.�P Greatness grows here. <br />Environmental Health Department <br />WATER PROVISION DECLARATION <br />Facility Business Name: <br />Facility Address: � 0 F122 3S — ___ "�qr_C-A, 9 5 34 <br />Street --City ZIP <br />Facility Business Owner Name: Phone:___ <br />Property Owner Name: <br />CaH1 bc')s 0, V_ ` i Phone: <br />Property Owner Address: 1Z�ewper�r fate S�;�ke 203 '1-,L4`6 � . '9 2-77 <br />Street City Zip <br />WATER PROVISION INFORMATIO <br />1. Number of houses, mobile homes, or other occupied buildings served by the water well(s): '-7 <br />2. Number of employees at the facility per shift: ':R,__ Number of shifts: _ 2 <br />3. Total number of employees, customers, and visitors at the facility per month, if variable: <br />4. Number of days that total number of customers, visitors and emplovees freauent the facility per month: <br />January <br />- <br />April <br />3 p <br />July <br />-3 <br />October <br />3 S <br />February <br />IL R <br />May <br />3 t <br />August <br />?r � <br />November <br />30 <br />March <br />'9; ( <br />June <br />3 ❑ <br />September <br />Zo <br />December <br />I ( <br />5. Number of yearlong residents: 0_ <br />6. Number of residents per month, if variable: <br />January % <br />April <br />July <br />October <br />February <br />May <br />t18 <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 wafer provision information of the facility changes. <br />Facility Business/Property Owner: (,,(q baLr �aiV,i _ Date: <br />Signatur e <br />1/13/2021 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />