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.-Can Joaquin County- Public Health Servi— <br /> Environmental Ilealth Division <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202- , .,one: 209-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEA LTH <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 Perma: 'Change or Operator 'Change or Owner <br /> 'C henge of Operator Ad dr en 'Change or Owner Address <br /> -Additional Employees permit IDM 0002937 <br /> Please Arole wry Corrections or Changer in Facility/Operator bjornmlion directly JCamp ID#: 39000099 * <br /> Site Name: KYSER FARMS#3 39-99 Location: W BACON ISLAND RD,STOCKTON <br /> Operator: KYSER FARMS <br /> Malling Address: PO BOX 343,STOCKTON CA 95201 Facility Phone#:(209)4647979 <br /> Legal Owner: DELTA WETLANDS Newflwnerl []Yes f,No <br /> Owner Address: 3697 MT DIABLO BLVD#320,LAFAYETTE CA 94549 Owner Phone#: (925)283-0216 <br /> Community Facilities Provided by Camp: Community Kitchen: w LJ No <br /> Men: Number of Toilets Number of Showers r Number of Lavatories _7 <br /> Women: Number of Toilets 3 Number of Showers 3 Number of Lavatories <br /> HousinE Accommodations to he Utilized this Year: Oct Dates_. <br /> Buildines Employees from !/ 1 /a/ to tvli/l�/crap�ira) <br /> Dorrritories 3 3 / rrom_I_I_to_I / Crap_ <br /> SF Dwellings /D 2-y <br /> Apartments Total Num her ofDaya to be used this Calendr Year-44 C) <br /> Owner Owned MH/RV Total Days Occupied by 25 or a we Empb)<es <br /> Owner Owned RR Cars Note: <br /> MHIRV Spaces Camps occupied by 25 or more employees for 60 or more days in a)tar <br /> TOTAIS require a Public Water System Permit. <br /> !S D <br /> ❑ Inactive <br /> Importann In order to protest your land use status,if camp will not be used this year but is intended for use in the future,Check this Box and return this application. <br /> Fee Schedule <br /> ❑Permanent Camp Annual Permit Fee: $35.00+ Number of Employees sn ® $1200 each=S 6'�7 <br /> 901) <br /> ❑ Orchard Camp Permit Fee: $95.00=S <br /> ❑ Transfer of Ownership: $20.00-S <br /> ❑ PermitAmendment Fee $20.00+ Number of Additional Employees (rd, $12.00 each-S <br /> ❑ Lute Application Fee: $70.00+ Number of Employees @ $24.00 each=S <br /> Fee mast be submitted with Application <br /> TOTALFEE DUE: S 6w?. dy <br /> RemitTOTAL FEE as CALCULATED ABOVE In the ENCLOSED Self-Addressed Envelope <br /> MAKE CHECKS PAYABLE TO: PIIS-EHD <br /> Applicant agrees to all necessary Inspections incident to issuance of s PERMIT TO OPERATE. Applicant agrees that this project(camp)shall <br /> operated and maintained in accordance with the applicable provisions or the EMPLOYEE HOUSING ACT, Chapter 1,Part 4 Division 13 of th <br /> California lfeahh and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code ofReguladoays� <br /> Applicant Name Kae r �< 1'1Nc Title �O �iytrlti'c� I V r lat.ltcu:PiY ElTarloerslop <br /> (Please PRwror PE) !/ ❑Corporal ion <br /> Address L 0 3`! ? r t Phone , <br /> Applicant Signature C . Date of Application ir <br /> Amount Paid Date P y ant ment Type ChecklRecelpt# Received By Account ID <br /> �(Q l 11�I() ! ✓ //�-�- (� _ 0002508 <br /> Facility ID Program Record ID PIE Assigned to I PWS ID <br /> 11 0002946 0270099 2755 1084-GALAPIA 00X1 37 <br /> Report 0:7086.rpt ftt/ C l D"-I J�� Application Pdnled:l IM00 <br />