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SAN JOA'QUIN COUNTY • PUBLIC HEALTH SERVICES ENAriRONMINTAL HEALTH DIVISIOfg 304 E WEHEt AVENUE a/THIRD FLOOR a STOCKTON CA q5202 a Phone: 209/468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYE HOUSING OR LABOR CAMP ❑Now Camp ❑CoRdltional Permit Annual Permit For Calendar Your ❑mended Permit ❑Multiple Years(Permanent housing Canips ontr) ate Approved • Change of Operator -Change of Owner ate Mulled: • Clumgc of Operator Address • Change of Owncr Address emit 4 • Additional Employees ,Camp ID 4 Please Note any f orrrMorts or ev In FaciMvhr)pemtar 9mw In_Jhrmation directly on thly form. Site Name: ,, ��; N 1`C roe 39-316 Location: MCDONALD ISLAND—1miNW/TR R Operator: ZUCKERMAN HERITAGE INC. STOCKTON MallingAddress: PO BOX $189, STOCKTON, CA 95201 FacRityPhone#: 209-469- 979 __..............—._..__._ -_--..._._...._..--_.._ _. .. - ----_..__..._._ ___.__...,.._. I,egalOwuer: ZUCKERMAN HERITAGE INC. �ewOwaer- ❑Fe---------------- ®�Nq Owner Address: PO BOX 487, STOCKTON., CA 95201 dwoerPhoneM 209-469- 979 Cominualty FsoAlitles Provided by Camp: Community Wulien: — es ❑so, Men: Number of Toilets 8 Number ofShowers 17 Number of Dories 12 Women:Number of Toilets Number of Showers Number of Lavatories Housiva ArcommodaMons to be UtlUzed this Year: all Employees Duildltues Tom° DDormitories: O�roroer Owned AhTiiC�' — o mitori Dwellings ——� -- Owner Owned RR Cars Apartments ----- ------ MER V spaces _ TOTAL of Both C OLUMNS Occupancy Dates: _ twm 1/ 1% 93. 12/ 31t' 99c.mv TotalNumbor of Days to be sued this Calendar Year from—/ / to / t Crop Y Total Days Ckcapied by 2S&r a tom Liapleyses L ——— —— — p �: c:vrtos o cu�xe z vy 15 ar awars eseipJop Jar ft!ar asar+s aybar rrgu:re a P*b#e Water aystses Pettit Cl InadtW, IasnmtrnaR' hi order to mterT your land we stains,ifeaM will not be uwd this year but iststeAvWfor wee Ix theJT ere,Ckeek thts s and return this ppppik;o&a. Fee Schedialt' y Permanent Camp ximual Peruilt S35.00+Number of Employees _102__$12.00 each-S 1259.00 FJ Orchard Camp Permit Fee=$!A-00=S 'D Transfer of O)%•nerahtp=$20.00=$ U Permit Amendment=520.00+Number of Additional Employees $12.00 each=S D Late Application Fee$70.00+Number of Employees (tT$24M each=$ - Fee mnst he etubrnitted with Application TOT AT,F T DIM- 12 5 9.00 1 RBMrr TOTAL FEE AS CALCULATED ABOVF IN THE BNCZOBBA Self-addressed ENVELOPE. AiAxu CHBcMPAv.1BLB M. PtW EUD Applicant.agrees to all neawmary inspections Incident.in Issuance o1 a PRRMTF TO OPERATE. Applicant.agrees that this project.(camp)shall b'operated and maintained in accordance with the applicable provisions of the TMMOYEE MUMr.,ACT, Charter 1,Part 1,Division 13 or the Health and Safety Code and Chapter 1,Subebapter 3.Title 25,California Cade ofRegaladons. Applicant Name ZUCKERMAN-HERITAGE, INC. Title CORRDINATO%.ftM,,,l,,, frrorporation (Please pRWor rrPE Mdress PO BOX $lit, STOECTON, CA 95201 Phone 209-469- 979 Applicant Signature l Date of Apatcation •-( J 11 i rrogram I6ecord Wo td1k* � KacU1ty110 uB'A0* Account IDi► cARa _-- Fee Amount Amount Paid Date f Pr nt Pa M Type `heckneoei t♦e ReceivedEmploy ! 0626e 0902525 1 002963 2 316 461342i461342 1h `—