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oaquin County-Environmental Health Depart, PAYM E N T <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 2094o8-3420 RECEIVED <br /> APPLICATION APR 18 2022 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE SAN JOAQUIN COUNT <br /> EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTAL <br /> HEALTH DEPARTME Z <br /> ❑New Camp []Conditional Permit ❑ Multiple Years(Permanent Ilousing Camps only) rl Annual Permit for Calendar Year <br /> ❑Amended Permit: *Change of operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#: 0002954 <br /> *Additional Employees <br /> State ID#: 39-0316-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000316 <br /> Site Name: ZUCKERMAN,ROSCOE 39-316 Location: MCDONALD ISLAND,STOCKTON <br /> Operator: ZUCKERMAN-HERITAGE INC <br /> Mailing Address: PO BOX 487,STOCKTON CA 95201 Facility Phone#:(209)464-8355 <br /> Legal Owner: ZUCKERMAN-HERITAGE INC New Owner? ❑Yes ❑ No <br /> Owner Address: PO BOX 487, STOCKTON CA 95201 Owner Phone#:(209)469-7979Ext: <br /> Community Facilities Provided by Camp: Community Kitchen? 0 Yes ❑ No <br /> Men: Number of Toilets Number of Showers 12 Number of Lavatories 19 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employee s <br /> Dormitories �� �� from 01/ O� 22 to J2/�/ 2-7— Crop 00 tzcio <br /> SF Dwellings from —0 1/_UL/ 2- — to )z 1,1 2-2- Crop <br /> Apartments <br /> Owner Owned ME/RV Total Number of Days to be used this Calendar Year: 305 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces No <br /> te <br /> TOTALS � Camps occupied by 25 or more Employees for 60 or more days in a year <br /> I •J Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> 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. <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fee $50.00+ Number of Employees _ @$15.00 each=$ 0 D d <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ <br /> Fee must be submitted with Application / <br /> TOTAL FEE DUE$ L4 10 . O D Y <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be ope ated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California health <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name 7 t'e.J Title (4ECU�Zr [I Partnership <br /> (Please PRINT or TYPE) � Worporation <br /> Address Q0 QJO)C LA S•1CC 4C+Cr1 Q 1 Phone ZG 9 _ —1 ,G <br /> Applicant Signature Date of Application 3 2-I /2-02 <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> �n L <br /> 4 1 :�r ^ 0002525 <br /> L <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002963 PR0270316 2765 9834-SUSZYCKI WA0461342 <br /> Report#:7066 Application Printed:12/2 2021 <br />