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SAN JOAQUiN Environmental Health Department <br /> COUNTY <br /> Greatnes groUis herd . <br /> WATER PROVISION DECLARATION <br /> Facility Business Name : Pahl ( If Od All% krgtfc <br /> Facility Address : 0 u 36S <br /> treet City zip <br /> Facility Business Owner Name : T-tfKair4,, Phone : <br /> Property Owner Name . �$ � ' ` i Phone : <br /> Property Owner Address : lFOOO , Wrh CCAYn �- ftnkcCat Cit' ' X3340 <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 : 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 <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 <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 : 71Wizooll <br /> Signature <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468 - 3420 F 209 464 - 0138 www . sicehd . com <br />