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i-. Joaquin County-Environmental Health Depal int <br /> 304 E Webe_ /enue-Third Floor-Stockton CA 95202-Pho. 209468-3420 <br /> APPLICATION 1"A tQ/ <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner.Address <br /> *Additional Employees <br /> Permit ID#: 0002937 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this ICamp ID#: 39000099 <br /> Site Name: KYSER FARMS#3 39-99 Location: W BACON ISLAND RD,STOCKTON <br /> Operator: KYSER FARMS <br /> Mailing Address: PO BOX 343,STOCKTON CA 95201 Facility Phone#:(209)464-7979 <br /> Legal Owner: DELTA WETLANDS New Owner? ❑Yes ❑No <br /> Owner Address: 3697 MT DIABLO BLVD#100, LAFAYETTE CA 94549 Owner Phone#:(925)2834216 <br /> Community Facilities Provided by Camp: Community Kitchen: AYesNLj <br /> Men: Number of Toilets t0 NumberofShowers Number of lavatories 7 <br /> Women: Numberof Toilets _ Numberof5howers Number of lavatories 4f <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buil�din .s Emolovees from1/,L/P4t0 oftif/ByCmp ,flyra) <br /> Dormitories 3 Y/ from_/_/_to_/_/ Crop <br /> SF Dwellings <br /> Apartments Total Number of Days to be used this Calendar Year <br /> Owner Owned MH/RV 'Total Days Occupied by 25 or more Employees <br /> Owner Owned RR Cars Note: <br /> MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year <br /> TOTALS require a Public Water System Permit. <br /> 73 S/ <br /> ❑ Inactive <br /> Important: In order to protect your land use status,if camp will not be used this year but is intended fm use in the future.Check this Box and return this application. <br /> Fee Schedule iD <br /> ❑Permanent Camp Annual Permit Fee: $35.00+ Number of Employees Is-/ @ $12.00 each-S 7 - <br /> ❑C] <br /> Orchard Camp Permit Fee: $95.00=S <br /> II''''�l Transfer of Ownership: $20.00=S <br /> ❑ Permit Amendment Fee: 520.00+ Number ofAEdtEonal Employees @ $112.00cach=S_ <br /> Late Application Fee: $70.00+ Number of Employees @$24.00 each=S <br /> Fea must be 1imilted sMth Application <br /> TOTAL FEE DUE: I 6 Ir <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope <br /> MAKE CHECKS PAYABLE TO: PHS-EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health <br /> and Safety Code and Chapter I,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name --aC211-- Title 46C.- , l-i 4R- Partnership <br /> (Please PRIM or TYPE) /' ❑Corporation <br /> Address 3`-F-' l PhonE X71`2t�]9 <br /> t Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment TypeReceived By Account ID <br /> a <br /> - ) 1 o f a7� 07,2;� 0002508 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> 0002946 0270099 2755 1084-RAMIREZ 0002937 <br /> Reoon#'.7065.mt Application Printed.11/20/2002 <br />