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S. aquin County-Environmental Health Departn 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑ New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) IN Annual Permit for Calendar Year V I ❑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 L&No Owner Address: PO BOX 487, STOCKTON CA 95201 Owner Phone#:(209)469-7979Ext: Community Facilities Provided by Camo: Community Kitchen? g Yes ❑ No Men: Number of Toilets Number of Showers , Number of Lavatories t i Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occunancy Dates: B it ings Employees O� Dormitories 2 from 91 /01 / toL/�Jr/ 1W Crop TO f-t P "� SF Dwellings Cl from 01_qtt ep tot2_al/J(p_ Crop Vl Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 5 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Not 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 /� Q(� �} Permanent Camp Annual Permit Fet $35.00+ Number of Employees ei)$12.00 each=$ 4-.l�V ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees C$12.00 each=$ ❑ Late Application hee $70.00+ Number of Employees L?$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 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 Cha ter 1,Subeha ter 3 Title 25,Cal'arni o e e[Re ulations. zuUf-�M&N N-E f�T�& 1� �t4C_ TI0►�S �1�Ci'0�❑ p Applicant Name '(' � S'( ,Il+11�ttAQ-\ Title p2�t Partnership (Please PRINT or TYPE) aCorporation Address g-7 T N S I Phone (W5--?9-7 61 Applicant Signature Date of Application l /s-- Amount Paid Date of. ayment Payment Type Check/Receipt# Received By Account ID 7 ( C _ 0002525 Facility ID Program Record ID PIE Assigned to PWS ID FA0002963 PR0270316 2765 2089-SOOD WA0461342 Report#:7066 Application Printed:10/13/2015