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06/21'2002 14: 37 2054633433 FIFTH F=LOOR PAGE 02 <br /> d20© <br /> WATER SYSTEM DECLARATION <br /> FACILITY ADDRESS, y Z 1 - / / <br /> �-o <br /> CITY 21? <br /> FACILITY BUSINESS OWNER: Z / <br /> rzG <br /> E <br /> PROPERTY OWNER: LG <br /> Please complete the following: NAME <br /> Number of houses, mobile homes, o'other occupied buildings served by the water well(s): T19s�rir.� � <br /> I�CJ/ti l C��L <br /> Number of employees at the facility per shift: Number of shifts: <br /> Number of employees at the facility per month, if variable: <br /> JAN T, FEB c.- MAR . APR r MAY <br /> JUL '_ AUG_ SEP_ _ OCT- <br /> NOV DEC a <br /> Number of Customers at the facility per month, if variable <br /> JAN cf)� FEB m fu1A;R MAY_ _^ JUN_Q <br /> ,0 041111 rrs' � <br /> JUL-- c;Y AUG i o0 9EP� �o OCT_! NOV <br /> OV <br /> Number of yearlong residents: <br /> Number of residents per month, if variable: �����/•4.ef.�.B�-e <br /> JAN FEB MAR_ APR MAY _ JUN <br /> JUL AUG SEP OCT NOV_ DEC <br /> Using the Information listed above, please IiI the box,that best describes the water provision at the facility, <br /> �- The well serves at leas,15 connections used by yearlong resioents <br /> Or 't regularly serves at least 26 yearlong residents. (Community) <br /> d T.ne well serves at least 25 of the same persons(i.e-employees, students)over six months per year <br /> (NTNC) <br /> �= The well serves 25 or more persons (not the same erson , i.e. customers, visitors)at least 60 days per <br /> year. (TNC) <br /> i The well serves five to! connections (I_e. houses, mobile homes,etc.)and does not serve water to an <br /> average of 25 individuals daily for more than 60 days out of the year. (State Small) <br /> The well serves less than 5 corrections and regularly serves 24 or less individuals daily though out the <br /> year. <br /> 1 (Vile)declare under penalty of perjury that the statements on this application are correct to my(our)knowledge. <br /> It is the owner's responsibility to notify this office if the operation of the fpcility changes to the extent it now meets a <br /> different deflniWn of a public water stem than dieted an this form, <br /> FACILITY BUSINESS OWNER �L— <br /> SI GNAT ATE <br /> PROPERTY OWNER' D <br /> IGNA7URE AT <br />