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oAN JOAQUIN COUNTY o PUBLIC HEALTH J..KVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E WEBER AVENUE a THIRD FLOOR a STOCKTON CA 95202 o Phone: 209/468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑Now Camp ❑Conditional Pormk ❑Annual Permit!.r Calendar I e.r <br /> ❑Amender Permit ❑Multiple Yeats(Permanent Hoang Cup,amp) to A prov.d <br /> • Change of Opermor •clo nge of Ownerale Malted: <br /> • Change of Operator Address • Change ofOwnerr Address rank d 002937 <br /> • Additional Employers mm ID# 39000099 <br /> Please Note an Carrecdow or a In F&cff&y10penuorVwner In orrnatfon directly on this form. <br /> R <br /> Site Name: #3 39-99 Location: W BACON ISLAND RD <br /> Operator. KYSER FARMS <br /> MaBtng Address: PO BOX 343,STOCKTON CA 95201 Facility Phone 0: 209464-7979 <br /> Legal Owner: DELTA WETLANDS NewOwmr ❑Yes 0 N <br /> Owner Address: 3697 MT DIABLO BLVD#320,LAFAYETTE CA 94549 Owner Phone#: 510-283-4216 <br /> Community Facilities Provided by Camp: Community Kkelion: sUe, ❑No <br /> Men: Numberof Toltots to Number ofShowsn_� Numberof Lavotoi le. <br /> Women: Number of Toilela—Zv— Number of Shower 3 Number of Lav,torlm IYC <br /> Houslne Accommodations to be Utilized this Year: <br /> B Ildln 'm to err BnUdInZ Enmloretr <br /> Dormitories! 5/ Owner Owned MR/RV - <br /> SF Dw.01nm /O 10 Owner Owned RR Can _ <br /> Apmimema MHMV Space, <br /> TOTAL of Both Coi,vNm. <br /> Occupancy Dates: p� <br /> from f / to lyl3L/ctt Cup tPOt.y Total Number of Dry.to he used this CRlendar Year <br /> 7�- — Taal Days Occupied by IJ or mo,,Employees <br /> Mm /_/_t. /_/_(lisp Nola: Cnmpc rvrupad by ZJ a nirrr rnip/aJres fur 6d wmorr r0?rr n Jim <br /> requi re a Pkhae IYM Sydem Pernik( <br /> ❑ Inactive imaeMonr: In order toproled yourlandum statux ifoamp mil not be used thisyear buttrlwpadMfdr"elm thefhtarr. GkerA Pus Boa and return <br /> rhes ewpliruriois. <br /> Fee Schedule <br /> I 6dFyoo <br /> EJ Permanent Camp Annual Permit$3500+ Number otEmptoyoes -s <br /> �'� $Iz.00 naris <br /> ❑ Orchard Camp Perndt Fee=$95.00-S <br /> ❑ Transfer of Ownership=$20.00-S <br /> ❑ Permit Amendment=$20.00+NmberarAddklemlEmploys" @$12.00meb=$ <br /> ❑ Late Application Fes$70.00+Number of Employees_ @$24.00 each=$ _ <br /> Fee must be submitted with Application TOTAL FEB DUE: OU 7 <br /> REMTr TOTAL FEE AS CALCULATED ABOVE IN THE ENfZOAED%elf-addressed ENVELOPE. A44Kff01PCXNPAFAELRT0. PIIS/Fill) <br /> Applicant agrees to all necessary Inspections Incident to Issuance of a PERMrr To OPEkATB. Applicant agrees that this project(camp)shall <br /> be operated and maintained In accorilance with the applicable provisions M the xm1 oyEs HOUffii0 ACT,Chapter 1,Pmt 1,Division 13 or the <br /> Health and Sk e(v Code an 1,sogrbxper 3,T 25,Calyb �CodeofRSgnhadoar. <br /> Applicant Name i L /L'../1M e-b/An/(�- /s"Ah../ .K"Ofbf rl Tithe ❑Pwarrmp ❑corpuistion <br /> (Flews Pawn,n7l) Address y Phone <br /> Applicant tilgnatnre _ Dale of Application <br /> Program Record IDM 270099 Facility IDM 002946 Aoceeml IDM 0002508 <br /> Arnourt tale or Pa_iomt I <br /> .� , 60 l x/97 I <br /> Emptysa a: ACCI ac 'Fact : PR R PWS Pt€: <br /> [*w 0��15a- <br />