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S; jaquin County-Environmental Health Departn DA SENT R <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-wo6- 4 (� 'VI RECEIVED <br /> APPLICATION DEC 0 9 2019 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE SAN JOAOUIN COUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTAL <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Vears(Permanent Housing Camps only) 1A Annual Ik"kTf J*PA'RVW ?n <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID 4: 0002954 <br /> *Additional Employees <br /> State ID#: 39-0316-EH <br /> EH ID#: 39000316 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on thisform. <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 /> OwnerAudress: PO BOX 487,STOCKTON CA 96201 Owner Phone th(209)469-7979Ext: <br /> Community Facilities Provided by Camp: �-/ Community Kitchen? Rf Yes ❑ No <br /> Men: Number of Toilets 75 Number of Showers Number of Lavatories q <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildim! Employees <br /> Dormitories Z from 01 / Ol / ZQ to ,Z /IL/ I0 Crop -VKV fAk' <br /> SF Dwellings t.r from /�/ ?� to /�/ 2U Crop ur <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3� <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces <br /> Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> L v=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 I� <br /> Permanent Camp Annual Permit Fee $50.00+ Number of Employees 24 a $15.00 each=$ '� <br /> 'transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees a $15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees a,$30.00 each=$ <br /> Fee must be submitted with Application 1 <br /> TOTAL FEE DIIE$ q{v <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 operated <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 ��,t� czr_PAA�1�If,/ Title Y(�I Idng�Y'C(� ❑ Partnership <br /> (Please PRINT or TYPE) 15ICorporation Address .0. �-�$� �L�,V`\ "Tl "law) Phone ZM-4(PQ—JCA40 <br /> 1 <br /> Applicant Signature '(6 V Date of Application 1� oZs <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0002525 <br /> L26 <br /> Facility ID Program Record ID PIE 1 v Assigned to PWS ID <br /> FA0002963 PR0270316 2765 9834-SUSZYCKI WA0461342 <br /> Renort#:7066 Application Printed:11/13/2019 <br />