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06/21/2002 14; ?' 209458:�aK: FIFTH %LCOR <br /> WATER SYSTEM DECLARATIC)N <br /> FACILITY ADnRESS: g v� 9/ 1 _ <br /> ST-ET � G7Y <br /> IIP <br /> FACILITY BUSINESS OWNER: <br /> E <br /> PROPERTY OWNER: <br /> P+ease cormplete the foil irg: N <br /> Number Of houses, mobile homes, a'-other oecuoied buildings served by the water Weli(s):_��T " <br /> Number of employee.at the facility per shift;,J' ;Z-- Number of it{s; Am <br /> Number of ernploye4e at the facility y <br /> y per month If variable: <br /> 1.AN <br /> FES__ <br /> -'" MARr`�_ APR _ MAY—L <br /> JUL AUG_ ; . SEP_ ' ' dCT <br /> NOV bEt✓ <br /> Number of Customers at the facility per month,if Y nabl : <br /> JAN �& rpr+; .7— <br /> FES VAR APR„ MAY _ JUN <br /> JUL AIJG_ 5EP OCT NOV-- DEC <br /> Number of yearlong residents: _ <br /> Number of residents per month, J variable: <br /> JAN PER MAR APR--- MAY JUN <br /> JUL AUG SCP_____— OCT� NOV__ CLEC <br /> Using the ,nformation listed above, please Check the box that best describes the water,prcvisfon at the facility, <br /> The well serves at least is connections used by Yearlong en s <br /> Or 't regularly servos at least 25 yearlong fvaidonfli. (Community) <br /> n Tne well serves at least 25 of the same persons(i.e.enployees, stldents)over six+months per year <br /> (NTNG) <br /> =7 The well serves 25 or more persons ( -qL a sjmg pperson i.e. customers, visitors)at least 60 da <br /> year. (TNC) - ' days per <br /> f�. The well serves five to 14 connections (L e, moises, mDbile homes,etc,.)and does no;serve wa•.er to an <br /> average of 2' ildlvlduals daily for more then 60 days out of the year, (State Small; <br /> 17: The well serves less than S connect+ons and regularly serves 24 or less individuals daily though out ffie <br /> year. <br /> I (We)declare under penalty of perjury that the statements on this applicatlort are correct to my(our)knowledge. <br /> It 's the owner's responsibility to notify this Office if the operation of the facility changes to the extent it now meets a <br /> different definition of a public waterstern then in tad on this form, <br /> FACILITY BUSINESS OWNER: <br /> NAT �Z-- <br /> D <br /> PROPER TY OWNER, �Z <br /> /S GNATURE �� ATLI <br />