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t QUi� <br /> SANJOAQUIN Environmenta � Health Department <br /> T I L = COUNT Y <br /> � , 67,� J;;/ Greatness grows here . <br /> WATER PROVISION DECLARATION <br /> Facility Business Name : �� � h4ewS + <br /> Facility Address : .D L , � n ' (, Zo �t� ? <br /> Street city Zip <br /> Facility Business Owner Name : ., y� Phone : 20I !AP.2 <br /> Property Owner Name : 12 Lj (: T Q1" ouA:5 LLC Phone : abxhy� <br /> Property Owner Address : , � , cl � <br /> Street ity 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 : <br /> 3 . Total number of employees , customers , and visitors at the facility per month , if variable : <br /> January April July October `S <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 o July October <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 zoo May August November <br /> March '7i June 'li September December Z- <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 /> Signature <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 1 F 209 464 - 0138 1 www . sicehd . com <br />