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JOAQUIN COUNTY a PUBLIC HEALTH S! CBS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 P WEHEp .AVENUE a THIRD FLOOR a STOCKTON CA 95202 a Phone: 2091460-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> U New Camp LI Conditions]Permit D Annual Petuk For Calendar Your <br /> D Amended Permit ❑Mumple Yemy(Permanent Iiombta('ampr"M DideAppreved--� <br /> • C�tnge of Cryer�lur •�luwge�t()��iter uta Mused: <br /> Change ofitper,uor 1JJrc;< Change ofchvmrA4dre,, erakp 0a293, <br /> • ndditioasl F:mpl�ycce <br /> !1C <br /> Please Note anv CnrrerWoltr or exit,Pbr,,MV4.)p alnr t-inner fnfomw and dlrecl lv On Ilth form. <br /> I <br /> I She Win": BACON ISLAND CAMP tl3 39.Q4 1"mtlonM1 W/BAC 1SL RD 1 'MI,Nk/MR i <br /> Operator. KYSER FARMS <br /> -- — --— -- — —i <br /> { Ma9htp Address; PO BOY 343,STOCKTON CA 95201 Fadfity Phone M 209.4:4-71r9 <br /> .-- ... — ....---- <br /> Legat Owner. DELTA WETL AONDS hew(hraer . EY-es- —Wo <br /> i uwiterlAOdrcss: 309 Ivl'r DIABL i BLVD s320,LAFA1'EII E CA 94549 Owner Phone R: 510-283-4210 <br /> I <br /> CommuniLv Fta:Wtlds Provided bsFC2mD. CestmunN.y KkC1ms: -4Yft c j,INo <br /> Men: Number of Totleu �L\ Number ol'Shewera o Numtxr of Iwvaorles <br /> r Women Number of j'Mlw�.' - Number of6aowen 3_ Number of Lavatories �r <br /> Ilouslae Accommodatioun to be UtilizedEE"Year. <br /> I3unWn c)aaet'Owsed 144 R\' sRJl�lb{I <br /> DarmNOt'Ms: 3 — <br /> SF DwrlHna. timer G.rsed RR Can <br /> Aparnrostr _— ATti.Rl'Spseea <br /> TOTAL Of BOER COLUMNS <br /> i OC[n�ICy— t": _ <br /> from /1 / / to h'1>11A crop /C to _ -_ TotalNamraer efDsys n be red this Calendar Yea i.- <br /> mom t / to 1 rrb IoW Days i/cawpad by 11 w sore Employees L.. <br /> p <br /> ---_ ---- yFlg: ;-;vrpt ou:yym ay:S or wrewAiyrr.�o�stlwaen cgraXar <br /> i .eyaNx,.Pa/Nle/Faw Skeen r essu4 <br /> ❑ Inactive laparetl: to order ro protect w'dtr land use stmas tfca sill nor hr tied rk•s Year N,x lrlates4MJbr use it,Orrfarvm ckerR IF,,E, �•�c�-ti, <br /> rhtsappNeaaI <br /> F'ee behetlEUe to <br /> —�Pennanen(Camp Annual Pernllt S3S00 i\smher orRmpbyees 51 $12.00 each S E'er <br /> u' Orchard Camp Permit Fee=.$95.00- 5 <br /> r Transfer orO wDership=S20.00= S <br /> i� Perutlt Amendment=$20.01� Number of Addmoual Baspleyees (40$12.00 each=$ <br /> '-' Lale Appllc2tlon Fee f`70.00+Naaher of Employees parb=S <br /> Fop mast be submitted with application TOTAI.FEE.DCT-: IS <br /> RSMn:J'OTAL FRE As CALCULATED ABOVE er Ting gr4mosup wIr-addreawd ENv-xLOPE. At Aw C)fecHEPArwBLeTo. PHS/EHD <br /> Applicant agretm In all nerrasary Insptrdnns Incklml to lmOntuv rR a PERMrr TOOPERAIT.. .ApplWant serer%that this project(camp)shag <br /> be operated and maintained in accordance with the aDpEcabie provisions Of the EMPLOYEE HOtISI NG AM ebanter 1,Part L mvision 13 ortae <br /> Hedltn arta,S4R41'Code and f1mpter t,Ssbebspter 3.Title?S,raWarnte Cade orRegrtFrrlow. I <br /> Applicant NamePIA c• 1 C C . bl I 1 Title_rr . Kp,,tnwcew I7 rorpot*nl u <br /> (wrur nxltrre.rren <br /> _addre&V !' �o r 343 �o..�t �A1 ,f� S�z'l Phone `1G y - 74 7 rr <br /> Applicant Slenatbre _ r Date or Application <br /> Ptogrom Reeor4 IDs 270x99 —f Fmgky UW W2946 Aceoar iEW 110025116 <br /> r—_1F-.e Amvun! - Amotrn! old Dateo an T�aymont llpe /C eck rmlPld r Recefrod Py_ <br /> r Finployas A Pac 10 PRS PHIS IDA -- F -i <br />