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1-�In Joaquin Comity-Environmental Ilealth Dep -IN cid <br /> 304 EWe, Avenue-Third Floor-Stockton CA 95202-I',. 209-468-3420 / <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Ycars(Penuanenl Ilonsin Cam a onl <br /> g I Y) El Appal Permit for Calendar Year <br /> E] Amended Permit: *Change ofOperatnr 'Change of Owner <br /> *Change or Operator Address 'Change of Owner Address <br /> •Additional Employees <br /> ` Permit ID#: 0010928 <br /> Please Note any Corrections or Changes in Parility/Operalar luforrualion directly on this Camp ID#: <br /> er a <br /> Site Ninue: TOSTA#1 HENRY Location: 20662 SAN JOSE RD,TRACY <br /> Operator: HENRY&LINDA TOSTA <br /> Mailing Address: 20662 SAN JOSE RD,TRACY CA 95304 Facility Phone#:(209)836-1286 <br /> Legal Owner: TOSTA,HENRY&LINDA(#1) New owner 7 <br /> ❑Yea ❑ No <br /> Owner Address: 20662 SAN JOSE RD,TRACY CA 95304 Owner Plrone#:(209)835.0687 <br /> Community Facilities Provided by Camp: Community Kitchen 7 ❑ Yes ❑ No <br /> r <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Numberof'roilets Number of Showers Numbcroftavalories <br /> Heasley Accommodations to lie Iltllized this Year: Occupancy Dates: <br /> Bulldines Employees <br /> Dormitories from -111 1 / Oa to !_Z/ 11 o rG ' <br /> SF Dwellings ( Crop <br /> Apartments j fronttsiF/-yY�tn_/ / Crop <br /> Owner Owned MI I/RV 'final Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> Mil/RV Space <br /> Note <br /> TOTALS 7L Ill Casnps occupied by 25 or more Employees far 60 or more days in a year <br /> El Inactive Require a PUBLIC WATER SYSTEM Permit <br /> linnortam: In order to protect your land use status,ifcamp will not be used this year bud is intended for use in the future,Check Ibis Box and return this application. <br /> ...( Fee Schedule /y <br /> 11YJ Permanent Camp Annual Perntil Fe $35.00+ Number of Employees -Ir ®$12.00 each=$ ._l�r7 '•' <br /> T Orchard Camp Permit Fcc $95.00-S <br /> Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment pee $20.00+ Number of Additional Employees <br /> ❑ late Application Fee 570.00+ @$12.00 each=S <br /> Number of Employees Q$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAI,FEE DIIF,S 10 140, Q D <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EIID <br /> Applicant agrees to all necessary Inspections Incident to issuance era PERMIT TO OPERATE. Applicant agrees that [his project(easnP)shall be operated <br /> and nmhslained In accordance with the applicable provisions of the EMPLOYEE DOUSING ACI',Chapter 1, fart 1, Division 13 of the California Health <br /> and Safety Code and Chapter 11,Igubchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name 611), 'Title —��u pti ❑Pannership <br /> (Please PRIM wTYPE) ��'777 . <br /> /' ❑Corporation <br /> Address f� A ` <br /> Phone 7�r �2 <br /> Applicant Signature Date of Application <br /> Amount Paid Date o/Payment Payment Type Check/R yips# Received By Account ID <br /> � X40 .0 D �1�0� IrG 0011126 <br /> Facility ID Program Record ID PIE 1 1 Assigned to PWS t0 <br /> FA0007393 -PRO500996- yy1?�,-)7S' 0018-TRINDADE N/A <br /> Round#.7066.m1 .�r.�f D U,b1t- !F}. <br /> ��(� Application Printed;402004 <br />