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n Joaquin County-Environmental Health Depar�ent 304 E�venue-Third Floor-Stockton CA 95202-"� 209468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps mAN) ❑Annual Permit for Calendar Year ❑Amended Permit 'Change of Operator *Change of Owner *Change of(Operator Address -Change of Owner Address 'Additlonal Employee Permit ID#: 0002937 Please Note a),Corrections or Changes in Facility/Operator Information directly on this I Camp ID#: 39000099 Site Name: KYSER FARMS#3 39.99 Location: W BACON ISLAND RD,STOCKTON Operator: KYSER FARMS Mailing Address: PO BOX 343,STOCKTON CA 95201 Facility Phone#:(209)464-7979 Legal Owner: DELTA WETLANDS New Owner 7 ❑Yes ❑No Owner Address: 3697 MT DIABLO BLVD#100.LAFAYETTE CA 94549 Owner Phone#:(925)283-0216 Community Facilities Provided by Camp: Community Kitchen: YesN Men: Number of'foilen to Numberof Showers �_ _ Number of lavatories 7 Worsen: Number of Toilets 3 Number of Showers .__� Number of lavatories 4} 1lousine Accommodations to be Utilized this Year: Occupancy Dales: �/ Buildings Employ ees froml/,L/0Ato 000`10✓ d'Crop �a s1.1 Dormitories d/ from_/_/_to_/_/_Crop SF Dwellings /O 2G Apartments Total Number of Days to be 9"this Calendar Year Owner Owned MH/RV Total Days Occupied by 25 or more Employees 16 Owner Owned RR Cars Note: MHIRV Spaces Camps occupied by 25 or more employees for 60 or more days in a year TOTALS require a Public Water System Permit. ❑ Inactive Important: in order to protect 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. Fee ScheduleI' eD ElPermanent Camp Annual Permit Fee: 535.00+ Number of Employees s� @ $12.00 each-S o5 7 ❑ Orchard Camp Perssit Fee: $95.00=S Transfer of Ownership: $20.00=S E3Permit Amendment Fee. $20.00 Number of Agional Employees n $12.00cach-S_ bale,Application Fee: $70.00+ Number of Employees @$24.00 each-S Fee must be amltted with Application TOTAL FEF.DUE: S � Remit TOTAL,FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope MAKE CHECKS PAYABLE TO: PHS-EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter I, Part 1,Division 13 or the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name �(,I�L-��par..yt3 Title ��1 , f./(1/(_ , Partnership (Please PRINT or TYPE) ❑••Corporation Address '?v3� �D 1 Phon�..a'XI` Applicant Signature .Q!✓ 11 yn. 1 Date of Application Amount Paid Date of Payment Payment Type (C%, Iditecelpt# Received By Account ID — 1 a o p� ✓ C 11 0002566 Facility ID Program Record ID PIE Assigned to /�--� PWS ID 0002946 0270099 275511 1084•RAMIREZ 0002937 Recon#'.7066 red I ✓ / D / T1 Application Printed.11/20/2002