Laserfiche WebLink
San Joaquin County-Public Health Services <br /> Environmental Health Division <br /> 304EWeber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 r <br /> APPLICATION ' <br /> _ - ENVIRONMENTAL HEALTH 1 <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> 171 <br /> Years Camp ❑ Conditional Permit ❑ Multiple Yes(Permanent Housing Camps only) E]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 Permit ID#: 0002937 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this <br /> Camp 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: DELTAWETLANDS New Owner? ❑Yes &No <br /> Owner Address: 3697 MT DIABLO BLVD#100,LAFAYETTE CA 94549 Owner Phone#:(925)283-4216 <br /> Community Facilities Provided by Camn: Community Kitchen: YCSNLJMen: Number of Toilet fW NumberofShowess _�__ NumberofLavatodes <br /> Women: Number of Toilet —.� NumberofShowers __ Number offavatories <br /> Housingsnmodations to be Utilized this Year: Oc u ar Piss: +' <br /> Buildings Emolovees from l /IIYIO�,�D✓Crop <br /> Dormitories -5 11/ from %/_to_/_/_Crap <br /> SF Dwellings /0 a O <br /> Apartments Total <br /> Number of Days to be used this Calendar YearXsv <br /> Owner Owned M WRV Total Days Occupied by 25 or more Employees <br /> Note: <br /> Owner Owned RR Cars <br /> MWRV 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 /> ❑ Inactive <br /> Important: In order to protect your land use status.if camp will not be used this year but is intended for usein the future,Check This Box and return this application. <br /> Fee Schedule (-L7op <br /> orchard❑Permanent Camp Annual Permit Fee: $35.00+ Numberld Camp mit Fee: @ $12 $95.00=$ <br /> ❑ �l Transfer of Ownership: $20.00—$ <br /> Permit Amendment Fee: $20.00+ Number ofAddRiamd Employees @ $12.00 each=$_ <br /> ❑ Late Application Fee: $70.00+ NumberofEmployen @$24.00 each=S <br /> Fee must be Lhenitted with Application <br /> TOTAL FEF.DUE: S---- <br /> Remit <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 1,Subchapter 3,Title 25,California Code of Regulations. r,� <br /> Title G.�3 5"L�'f"K� ys Partnership <br /> Applicant Name �60r l%nrphdS ❑Corporation <br /> (Please PRINT or TYPE) '! <br /> Address R) �D Lb �D/ Phone '70 I/-74 <br /> Applicant Signature Date of Application <br /> Y <br /> aid Date of Payment <br /> Pa mant T e Check/Recelpt# Received By Account ID <br /> Amount PYP <br /> 0002508 <br /> PIE Assigned to PWS ID <br /> Facility ID Program Record ID 0002937 <br /> 0002946 0270099 2755 1084-RAMIREZ <br /> Application Printed:11/19/01 <br /> Report a:7066.rot <br />