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SAN =10 A Q U I <br /> : . ..:.Y . ErrvilrOnmentam Health Department <br /> COUNTY <br /> Greatness grows ner--e. PA2200OZ6 <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: <br /> Facility Address: <br /> Street r city Zip <br /> Facility Business Owner Name: � '!���}\ ` �--,� r��`.,�' _ Phone: <br /> Property Owner Name: `��k4�,t�, ..,�� � 4 ;•-;�5 Phone:�d�'`�`�� <br /> Property Owner Address: �Z�� � '�- v�c.��� ;:,�-• ��-l., ��--=s ��.__,� <br /> Street t 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: Number of shifts: 1 <br /> 3. Total number of employees, customers,and visitors at the facility per month, if variable: <br /> January April LAJuly h>y October <br /> February May August lj November (, <br /> March June September p December y <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January April (24) July , ,`.'_ October <br /> February `�f,� May . ,;,. August %' C ` November <br /> Marches June September '.% December <br /> 5. Number of yearlong residents: <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 /> Facility Business/Property Owner: X Date: !, <br /> Si nature <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br />