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?A2200045 Environmental Health Department -COUNTY-.... :.* · •. WATER PROVISION DECLARATION Facility Business Name: Lost Isle Resort, LLC Facility Address: 11050 W. Acker Island, Stocton, CA 95219 Street City Zip Facility Business Owner Name: Lost Isle Resort, LLC / David Wheeler Phone: 408-836-4427 Property owner Name: Lost Isle Resort, LLC / David Wheeler Phone: 408-836-4427 Property Owner Address: 1475 Saratoga Ave, Suite 100, San Jose, CA 95129 Street City Zip WATER PROVISION INFORMATION 1. Number of houses, mobile homes, or other occupied buildings served by the water well(s):_l_ 2. Number of employees at the facility per shift: ____ Number of shifts: ____ \/_~-, ~ 3. Total number of employees, customers, and visitors at the facility per month, if variable: January April 7-l _:,o July \o 0):.) October "'2.--4. Number of days that total number of customers, visitors and employees frequent the facility per month: January v April "3,:;. July ( October March June :, September :, December '\..., 5. Number of yearlong residents: ~ 6. Number of residents per month, if variable: ttt1 January April I July October February May August November March June September December I declare under penalty of perjury that the statements on this application are correct to my knowledge. It is the owner's responsibility to notify this office if water provision information of the facility changes. 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sjcehd.com