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SAN JOAQUIN <br />COUNTY <br />Greatness grows here. <br />Environmental Health Department <br />WATER PROVISION DECLARATION <br />Facility Business Name: <br />Facility Address: ` <br />Facility Business Owner Name: R t C I % <br />Property Owner Name <br />Property Owner Address: <br />Street <br />LLL <br />til Hai ct Ktllr-t N'/e� r �.. <br />�, n 4�vx i rod <br />Street <br />WATER PROVISION INFORMATION <br />�S 46 <br />Phone: oz v9 - 339-a r► 2- <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:. 1 Number of shifts: <br />3. Total number of employees, customers, and visitors at the facility per month, if variable: <br />s�-�1 <br />January <br />_ cl <br />Aprilj <br />- <br />July <br />- '� <br />October <br />� • ,� <br />February <br />_ y <br />IMay <br />lt�l <br />August <br />y - Z <br />November <br />1 3 -S <br />March <br />>,5r <br />I June <br />September <br />7 <br />December <br />1 .3� 5 <br />4. Number of days that total number of custorrters, visitors and employees frequent the facility per month: <br />January April 3 -J* July y-- % October aj <br />5. Number of yearlong residents: <br />6. Number of residents per month, if variable: <br />January <br />I declare under penalty of perjury that the statements on this application are correct to my knowledge. It <br />April <br />� <br />July <br />� <br />October <br />-- S <br />February <br />(� <br />May <br />[f - ? <br />August <br />y - Z <br />November <br />p <br />March <br />3 - <br />JuneY <br />September <br />7 <br />December <br />3 �S <br />5. Number of yearlong residents: <br />6. Number of residents per month, if variable: <br />January <br />I declare under penalty of perjury that the statements on this application are correct to my knowledge. It <br />April <br />� <br />July <br />� <br />October <br />February <br />(� <br />May <br />August <br />Q <br />November <br />p <br />March <br />0June <br />September <br />December <br />10 <br />the <br />owner's responsibility to notify this office if the water provision information of fhe facility changes. <br />Facility Business/Property Owner: <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sjcehd.com <br />