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San Joaquin County-Environmental Health Department 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 A►►LICAMN ENVIRONMENTAL HEALTH PERMIT TO OPERATE BY: EMPLOYEE HOUSING OR LABOR CAMP �� ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) :annual Permit for Calendar Year (l ❑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 f I 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?Ves No r l., Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: Occupancy Dates: B di s Employees Dormitories t J from a/O / to / ( Crop SF Dwellings ~ fro /a Ito /J/ 1-1 Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: r FM E N T Owner Owned RR Cars Total Days Occupied by 25 or more Employees: "I V E D MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year FEB 16 Require a PUBLIC WATER SYSTEM Permit 1�Z 1 El 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. SAE NOR Qt UPAR E COUNT' AL Fee Schedule IJI�I ARTMENT ` } Permanent Camp Annual Permit Fee $50.00+ Number of Employees � @ S 15.00 each=$ 1tC V '❑ 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 1v t�a TOTAL F EE 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 opera ed and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT, Chapter 1, Part 1,n Division 13 of the California He lth and Safety Code and Chapter I,Subchapter 3, 'tle 25,California Code o R gu/adons. n`S(J, ` Applicant Name Title 1 0 v' Q � cb�❑P ership (Please PRINT orT E) (� Orpptatlpp Address g Vn �-� I Phone Applicant Signature Date of Application 1 Amount Paid ate of Pa ment Payment Type Check/Receipt# Received By Account ID 'zj / y G ^^V (,I �I n 0002525 Facility ID Program Record ID PIE Assigned to PWS ID FA0002963 PR0270316 2765 9834-SUSZYC KI WA0461342 Report#:7066 Application Printed:11/19/2 20