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PA2 ? 00033 <br /> S A N. J Q A Q U I N Environmental Health Department <br /> COUNTY <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: CL Q ' P-r <br /> Facility Address: Q 9111) 7-dt,2-kr J <br /> 7C, <br /> City Zip <br /> Facility Business Owner Name: Uff��c� c' Phone: 62-& Z k� <br /> <'(- <br /> Property Owner Name: c_L� E'5 y . Phone: <br /> Property Owner Address: CA - qYS-(�!> <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): <br /> 2. Number of employees at the facility per shift: ' 7 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 1116 <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 5— <br /> February May August November <br /> March 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: Date: <br /> ure <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjoelid.com <br />