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�. S DAQUIN COUNTY • PUBLIC HF,ALTH SEI) .S e,NVIRONMFNTAI. HEALTH DIVIs10 ' 304 E WEBER AVENUE • THIRD FLOOR • STOCKTON CA 95202 • Phone: 209/468-311Aynnen i APPLICATION RECEIVED ENVIRONMENTAL HEALTH KQ2 9 20 PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP SAN JOAQUIN COUNTY 'UBLIC HEALTH SERVICE New('amp i('ondifinnal Permit � Auoual Permit FAi''(1ONMEKIAaHEALTH DIV SION I.1 Amended Permit Multiple Years(Permanent Ilousing Camps onl),) Date Approved • C'hangeofOperator Whange of Owner Date Mailed: • Change of Operator Address • Change of Owner Address Permit It • Additional Fniployces Ca:�i ID# Please Note any Corrections or Chau cs in Faccijlit�/O�er•ator/Owner hi urination direct) on this forst. Site Name: J� ' Location: ------------------------Cr__e_� // 1 �3_Y ° e /_rye Operator: rr�Ge C�+,Cly --------------------------------------- ------------- - / - Mailing Address: �— P p /� J . L Facility Phone#: j --- Legal 011'ner:------ di.--(/l -- -- -- ----- G�/Y ct4_rC___ PO____- _ __ New Owner Yes L�Nd 1LLOwner Address: 2 3 L 3 c� 4,e2, ,e�I-ee /6LX O�yner l'houe#: ZOy-�J� ll�f�Gl Community Facilities Provided by Camp: Community Kitchen: ❑ Yes J`. No Melt: NunlbcrofToilets Numberol•Showers_ Number ofLavatories__ Women: NumberofToilets NumberofShowers NumberofLivatories Housing Accommodations to be Utilized this Year: Buildings Fnmloyces Ituildines Enwlmres Owner Owned M11/KV Uormilories: _ -- SF Dwellings Z Owner Owned KK Gars Apartments _ N11111/111%'Spaces _ TOTAL of loth COLUNINS Occupancy Dates: from L/-L/L)Vto�/ (/ 'Crop_ i ---- Total Number of Days to be used this loyeeYear Total Days Occupied by 15 or more F:npyloycc% from -✓to_�_�_ Crop_ Note: Canrps oc•c•upiecl Im 25 or more euq?l�I'ees for•60 or more da):v a fear require a Public Hiner Sj stent Permit. L l i tlactiVe lnrporlanl: hl order to prolec•l your land use slants,if camp will not be used this rear but is intended for use in the future, Check this-Box and c clurn this n c rlication. Fee Schedule Permanent C:unp Annual Pcruiiit $35.00 1-Number of Fnyrloyees % $12.00 each=$ — ❑ Orchard Camp Permit Fee=$95.00=$ I 'i'raiisfcr of Ownership=$20.00=$ ( � Perlllll Anlendnlenl =$20.00 ' i�uanber orAdditimud Employee, cr,�$12.00 each=$ I- Late Application Fee$70.00+Number of Employees__ @$24.00 each=$ Fee nnlst be submitted with Application TOTAL FEF DUE: $ l��• L 0 RENIIT TOTAL FEF AS CALCULATED ABOVE iN TIIF.ENCLOSED self-addressed I:N\'FLOI'I?. fl1.18B CHECKS PAYABLE 7.0: PiiS/ElID Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the ENivi.oylsF,HOUSING Ac,r,Chapter 1,Part I,Division 13 of H e llealth and Softy Corte and Chapter I,Subchapter �3,Title 25,California Code of Regulations. Applicant Name u t `�� v l /Title a o,&4�u-^ karinership/J:C orpo ation (Please PRINT or 7TPn Address .2,325 Y )-r x ko PlIolle Applicant Signature G��-1 Date of Application Program ltecord ID# Facility iD# Account ID# Amount Paid Date ,Pa ment Payment Type Check/ ecei t# Received B I / Employee#: Acct#: Fac ID: PR#: PWS ID#: P/E: