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`„ .. OAQUIN COUNTY a PUBLIC' H- VICES 1-AY FMr I d'�i' I�'IRONbIfiNTAL HEALTI L N '' '` 1SBER AVENUE s THIRD FLOOR s S `4'G A 95202 209r468-3420 DEC I''H999�7 • �� D��c��cf / APPLICATION ENVIRONMENTAL HEALTH PUBLIC 'ALTHScUIS" FU3LIC HEALTH SERWti:E". PERMIT TO OPERATE ENVIRONMENTAL HEALTH DIVISION EMPLOYEE HOUSING OR LABOR CAMP u New Camp Conditional Permit Annual Permit.For Calendar Ye r 11991� ❑Amended Permit LJ Multiple Years(Permanent Housing Camps a*#) Ras Ag roved _Change of Operator -Change of Owner Pate MQUed- _Change of Operator Addrers Change of Owner Addreslr etmit ri 1 002954 -Addition a]Employees IC'amp ID# 39-31 Please Note any Csrneedms or<Awiges in FastW0peA;9W 0wwd lwfbr natior directly on this corm. - - -- ---- ------- -----------------------------•------•---------------- ------- ---•-----------.._..--- - --- ------ --- - ---------------------------------- Site Name: ZUCKERMAN,ROSCOE 39-316 Location: MCDONALD ISLAND lmi NW/TRNR -------------------------•---------------------•-----•----... - .-------- -------------------- .------------ .--------------------------._.-----------------------------------.----------------•-------- Operator: ZUCKERMAN-HERITAGE INC STOCKTON I ",Address: PO BOX 487. STOCKTON CA 95201 Facility Phone#: 209 464 8355 Owner: ` ZUCKEKMAN-HERITAGE INC ' 1 d 'New Owner D Yes Owner Address: PO BOX 487, STOCK'I'ON CA'�fi-50I Owner Phone#: 209-464- 355 -- - -- - ---- - - --- - - _.: - -- - - - -----------•-------.----•--------------------•-----•-- --------------------- - - ---- --•---------� Community Facilities Provided by Camp: Community Kitchen: I_-es ❑No Men: Number of Toilets 8 Number of Showers_17 Number of Lavatories-J-2- Women Number of Toilets Number of Showers Number of Lavatories Ilaushig Accommodations to be Utilized this Year: Bull diaas Emoloyee uildbtas Erutotoy Dormitories: _ Owner Owned MH(RV _ 5F Dwellings Owner Owned RR Cars Apartments _ AMRV Spaces TOTAL of Both Cot u>kfrxs Ck;cU DttG86'. 6ro 1/94, 12 / 3 y 98Crop -_--- _- _- Total Number of Days to be used this Calendar Year from—/—�—to—/_/ Crop Total Days Occupied by 13 or mare Employees 'L--39. 1 NW: Camps viceupte¢ov 2.5 or mare-empio►ties por o0 or more d�� r require a PaNk P40er System Peradit ❑ line ive IsnpmtoW. in order to protect your land use status,ifcamp will not be used thv;vear but Is-ixtrxded fiw axe in the Jktxre.Check this Roo ptu m this appRcr 04W Tee Schedule e I CX Permanent Camp Annual Permit$35.00+Number of Fmpleyees 102 ra 912.00 each=$ 1259.0 Orchard Camp Permit Fee=$95.00 $ � 0 Transfer of Ownership=$20.00 E Permit Amendment=$20.00+Number of Additional Employees A$12.00 each ❑ Late Application Fee$70.00+Number of Employees $24.00 each= Fee must be submitted with AppdcaOo.n TOTAL FEE DUE: 173 • _I G REMTl'TOTAL FEE As CALCULATED ABOVE IN THE ENCLOSED set`>addressed E'_VVELOPE.r4LiXF CHECKSP.41_9eLE TO: PHS/EHD Applicant agrees to all necessary Inspections incident to Issuance of a PERMIT au OPERATE. Applicant agrees that this project(camp) all be operated And maintained In Accordance with the applicable provialons'of the'E mMOYEE xooslNG ACT,Chapter 1,Part 1,Division 13 of the taJlh and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code prRekw1 adenS. _ Applicant Naane(pieaseprintortppe,, Zuckerman-Heritage, Inc. _7ltle Coordinator- - A ress P.O. Box 487 Stockton, Ca 95201 Phone 469-79.7 Applicant Signature— SA-µ _ --- Date of Application - - - ----- - - - - -- Fee Amount—T Amount Paidd T�Date of Payment-- -- i Payment pe eoefptei l Received a s9 D� i �as9.c� !z zz _? 1 Am as 7 - —----- - Emptoyes* 0626 1 Acci*0002525 -T—Fat ID: 002963 PR* 270316 1 PWS ID*: -T-- /E: 2755 - -----------1- ------!------ ----�--461342461342---�- —