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PAYMENT soaquinlunty-Environmental Health Departs RECEIVED 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 SAN JOAQUIN COUNTY APPLICATION ENVIROMENTAL ENVIRONMENTAL HEALTH HEALTH OMENTAL PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year Zv 1 C ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#• 0000460 *Additional Employees State ID#: 39-0120-EH EH ID#: 39000120 Please Note any Corrections or Changes in Facility/Operator Information directly on this form. Site Name: CANTON LABOR CAMP 39-120 Location: 13631 N HURD RD, LODI Operator: CANTON,ANTHONY Mailing Address: 1231 MIDVALE, LODI CA 95240-0505 Facility Phone#:(209)334-9590 Legal Owner: CANTON,ANTHONY New Owner? ❑Yes ❑ No Owner Address: 1231 MIDVALE, LODI CA 95240-0505 Owner Phone#:(209)334-9590 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes No Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Honig Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories from l l ? to i 2/S I/ t 7 Crop SF Dwellings from _/ / to /_/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces LQk TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑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. +S.v"'i) Fee Schedule ,5 : ' El Permanent Camp Annual Permit Fe( $3596+ Number of Employees @$),24 each=$ �� ' ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ Fee must be submitted with Application TOTAL FEE 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 operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1, Part 1, Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. ,y /�� Applicant Name �� TV � //O/Y Title (/ !Y /y El Partnership (Please PRINT or TYPE) ❑Corporation Address �db/ — CAL_ Phone 207' Applicant Signature �� Date of Application 14,10 Amount Paid ate of Payment Payment Type Check/Receipt# Received By Aco6unt ID -3 ( D 2 0 t G 1 L 0000453 Facility ID Program Record ID PIE CJ Assigned to PWS ID FA0000454 PR0270120 2765 6219-DUNCAN WA0515730 Report#:7066 Application Printed:10/20/2016