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Sa.. ,oaquin County-Environmental Health Departmen. PAYMENT 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 RECEIVED unt t I f Ef11 J APPLICATION SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ENVIRONMENTAL PERMIT TO OPERATE HEALTH DEPARTMENT EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Yea ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID# 0002954 *Additional Employees State ID#: 39-0316-EH EH ID#: 39000316 Please Note any Corrections or Changes in Facility/Operator Information directly on this form. Site Name: ZUCKERMAN, ROSCOE 39-316 Location: MCDONALD ISLAND,STOCKTON Operator: ZUCKERMAN-HERITAGE INC Mailing Address: PO BOX 487, STOCKTON CA 95201 Facility Phone#:(209)464-8355 Legal Owner: ZUCKERMAN-HERITAGE INC New Owner? ❑Yes No Owner Address: PO BOX 487,STOCKTON CA 95201 Owner Phone#:(209)469-7979Ext. Community Facilities Provided by Camp: Community Kitchen? Yes ❑ No Men: Number of Toilets Number of Showers Number of Lavatories 9 Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories from 9Ll_0Ll1&_to L2_l3Ll1Z__ Crop SF Dwellings —I_— from 01/0/1"8 to(3/31 Crop i(f Apartments Owner Owned ME/RV Total Number of Days to be used this Calendar Year: 3 1115 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: --a— MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year © ® 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 Schedule _)(.1 I,, Permanent Camp Annual Permit Fee $50.00+ Number of Employees � @$15.00 each=$ 3 v D ' Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @'$15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application f (� TOTAL FEE DUE$ J (J Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to 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 1, Part 1, Division 13 of the California Health and Safety Code and Chapt r I,Subcha ter 3,Title 25,California Code o Regulations. .� zz�aa ar..aN.14" c. Applicant Name Tr„LV e"V1.��i' I Title ��':�S 'p-((e�J� ❑ Partnership (Please PRINT or TY)-E) 1.l /� —r Corporation 07 Address D 0 t--` 4 -�'oL' e, vy� A `'I�a(7 Phone -7 . Applicant Signature Date of Application 1 I ? I Amount Paid Date'cf Payment Payment Type Check/Receipt# Received By Account ID t 6 ( � 0002525 L PA eZ \ / Facility ID Program Record ID PIE Assigned to PWS ID FA0002963 PR0270316 2765 2089-SOOD WA0461342 Report#* 7066 Application Printed 10/23/2017