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?A2Z00045 <br /> SARJOAQUIN Environmental Health Department <br /> —COUNTY <br /> WATER PROVISION DECLARATION <br /> Facility Business Name: Lost Isle Resort, LLC <br /> Facility Address-, 11050W. Acker Island, Stocton, CA95219 <br /> Street City Zip <br /> Facility Business Owner Name.- Lost isle Resort,LLC/David Wheeler Phone: 408-836-4427 <br /> Properly Owner Name: Lost Isle Resort, LLC / David Wheeler Phone: 408-836-4427 <br /> Property Owner Address: 1475 Saratoga Ave, Suite 100, San Jose, CA 95129 <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: qAcu t <br /> 3. Total number of employees, customers,and visitors at the facility per month, if variable: <br /> -January C103 April Z-I Z�10 July October Z. <br /> February may I 0 A 0 C August ),n November CLL-;)_ <br /> March June tDW) I September_ December <br /> 4. Number of days that total number of customers, visitors and employees frequent the facility per month: <br /> January t-1,, April I -7,.> I July October <br /> February May IL August November \'L. <br /> March June September *Sz') December ti <br /> 5. Number of yearlong residents: <br /> t <br /> 6. Number of residents per month, if variable: <br /> January April i i July October <br /> February May I 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 water provision information of the facility changes. <br /> Facility Business/Property Owner: = Date: U,) 742 <br /> Signature <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.corn <br />