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Q N �•-.� 0/�Q� � I v ErcvArO rs tTeOrrot�c.. B-$��It&o �3a�ga�rtrreeret <br /> - -- CCNU NTY-__-.. <br /> .r..n e� yrowz hc,-c. <br /> WATER PROVISION DECLARATION <br /> Facility Business Nama: � � / <br /> �c4 �sPY ! � ��6�/� <br /> Facility Address: � �DO C!J�/r�iGfiGrn¢Y /�/ GU/�/ 9Sz`�Z <br /> Facility Business Owner Nama: �iY'Y`iv/J<f ,���i�!! ci Phon���33�3i/� <br /> Property Owner Nama: 5.4,r�^' .�.5 ool;S�!/t Phones: �. <br /> Property Owner Address: F ` � <br /> Stmat CIH 2�P <br /> WATER PROVISION INFORMATION <br /> t. Number of houses, mobile homes, or other occupied buildings served by the water well(s):� <br /> 2. Number of employees at the facility par shift: � Number of shifts: � �Zy `iie> <br /> 3. Total number of employees, customers, and visitors at the facility par month, if variable: <br /> January —f0 April D Jub d OMObar _ <br /> February O May Augus[ Q NOwmbar � a <br /> March Jurre O September Q Oeoember _ O <br /> 4. Number of dayg that total number of customers, vlsltora end employees frequent the facility par month: <br /> January O April � 18 July � O 00[ebar //O <br /> Fabmary _ � May Augual � Nevaml»r �Q <br /> March Junes September rj OaOamber /�.� <br /> 5. Number of yearlong residents: <br /> 6. Number of residents per month, IL variable: <br /> January April July Opmber <br /> Fabmary May Augual NOvambar <br /> March Juno Sapbmbar Oaeembar <br /> /dec/era under Pana/fy o1 psrJury that Yha statamenfs on this app//cation era coriact to my know/edge. /t is the <br /> owner's responsJbi/!ty to notify t/hi/s office!f the wate�-r/%�yp/�JproNslon lnformatian of the fac!/fty changes. <br /> Facility Businass/Proparty Owner: �/ /i27K�/,��a'�J�� Date: '� /Z <br /> siorem <br /> t 866 E. Hazelton AYanuo I Stockton, California 95205 I T 209 468-3420 I F 209 464-0136 I www.sjcohd.com <br />