Laserfiche WebLink
�1 �l <br /> an Joaquin County-Public Health Services r~ �,.° 91=•. r� <br /> Environmental Health Division <br /> J <br /> 304 F.Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 <br /> .tery <br /> • .� J I(1L1 APPLICATION <br /> ENVIRON?CENTAL HEALTH `'/�N,JtJAy(IIN(I'(it IN <br /> .1 PERMIT TO OPERATE If 1i rt41f.(SY <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 or 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 Charges 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 /> Melling Address: PO BOX 343,STOCKTON CA 95201 Facility Phone#:(209)464-7979 <br /> Ltgal Owner: DELTAWETLANDS New Owner? ❑yes No <br /> Owner Address: 3697 MT DIABLO BLVD#100,LAFAYETTE CA 94549 Owner Phone#:(925)283-4216 <br /> Communitv Facilities Provided by Camp: Community Kitchen: YcsN y <br /> Mtn: NumberofToilets /� Number of ShoweNumber of Lavatories 7 <br /> rs �_ <br /> Women: Number orToilels Number of5howers R_ Number orlavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy ants: <br /> Buildines Employees from / d'1A.vto r_A/ Crap <br /> Dormitories J _ <br /> from /_%to %/_Crop <br /> SF Dwellings /0 Total Number or Days to be used this Calendar Year—%% <br /> Apartments <br /> Total Days Occupied by 25 or mor<Eote: es <br /> Owner Owned MH/RV Note: <br /> Owner Owned RR Cars <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 /> F <br /> ❑ Inactive <br /> important: In order to protect your land use status,ircamp will not be used this year but is intended for use in the future,Check this Boa and return this application. <br /> Fee Schedule 6W*Da <br /> ❑Permanent Camp Annual Permit Fee: $35.00+ Number of Employees S/ 8312.00 each <br /> ❑ Orchard Camp Permit Fee: $95.00-S <br /> — <br /> Transfer Transfer of Ownership: 320.00-5 <br /> Permit Amend mem Fee: $20.00+ Number of Ahdllional Employees C $12.00 each-S_ <br /> ❑ Late Application Fee: $70.00+ Number of Employees @324.00 each-S <br /> Fee must be Qmitted with Application TOTAL FEE DUE: S gg 477 <br /> Remit TOTAL FEE as CALCI ILAT'1'1' 1 DOVE in the ENCLOSED Self-Addressed Envelope <br /> MAKECIIL� iSPAYABLETO: PHS-EHD <br /> Applicant agrees to all necessary Inspections incident to Issuance ofa 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 I,P�1-e3a 3� <br /> and Safely Code and Chapter 1,Subchapter 3,Title 25,Californiathe California Health <br /> Code of Regulations �y-��e.' <br /> Title �,�) �•..l.r4J-A'�A Partnership <br /> Applicant Name �Es2� >=ap1..lS ❑Corporation <br /> (Please PRIM or TYPE) � <br /> Address � Phone aD l -W <br /> Applicant Signature 1L(6G? s Date of Application <br /> Amount Paid Date of Payment Payment Type ChecWRecelpt# Received By ;;00;02508 <br /> t ID <br /> ✓ �(n(n, �D <br /> PIE Assigned to ID <br /> Facility ID Program Record ID 0002937 <br /> 0002946 0270099 2755 1084-RAMIREZ <br /> Application Printed'. 11/19+01 <br /> Recon a 7066 not <br />