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SAN OAOUI N <br />----COUNTY-- <br />Greatne.ss <br />WATER PROVISION DECLARATION <br />Facility Business Name: D'-L g T(ZAµ7 pofZ.-t- <br />Facility Address : Z.'? 27 ff, /,·Hi@ A-c.i! 12D-Street <br />Property Owner Name: <br />1 <br />/4 A I-JT1?ul City <br />Phone: <br />Phone: -------- <br />Property Owner Address: <br />----�'--"'""'--"'-�-'-----l:,,-.!!.L..:l!!::-==-,-.:....;,,....:s_;_;=-_...lJ'""--=-------'t:........:::.!�F..,.i;...!=:.!�--l:.-:�--L-,..LL.L.:....J!.,,,,""). <br />WATER PROVISION INFORMATION <br />i.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: _4= ____ 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 <br />February May <br />March June <br />5.Number of yearlong residents: ____ <br />6.Number of residents per month, if variable: <br />January April <br />February May <br />March June <br />July October <br />August November <br />September December <br />July October <br />August November <br />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 />Facility Business/Property Owner: _,,./.......,.�-/----,2-•-�•-•----·g---t-:'-�:::_===-=--=----Date: / / - 9 -cJ-D <br />1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com <br />l <br />11 <br />Street City -Zip -