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SAN J OAQ U I N Environmental Health Department <br /> COUNTY <br /> , r•tC�t:r�c>,;s ;1�-c�atrs l��:rc. �ii�0 �O <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: <br /> Facility Address: <br /> Street City Zip <br /> Facility Business Owner Name: l vie rb J 9AGCU1� _ Phone:__.'P_09 C1 7�.? <br /> Property Owner Name: Phone: <br /> Property Owner Address: _C:,1C7 FqA — _ '�,� <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):_t <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 April July October <br /> February May August November <br /> March June September December <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January April July October <br /> February May August November <br /> March June September December <br /> 5. Number of yearlong residents:_41JI� <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 /> 1 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: 9044%5-- `�✓��� _ Date: _ <br /> Signature <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />