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-oaquin County-Environmental Health Depart <br /> 1 1868 E. �Iton Avenue-Stockton CA 95205-Phone: 2h ;8-3420 <br /> CEI iw';IE""1 <br /> n;r, <br /> SAKI JOA OUIN COUf"TY APPLICATION <br /> E',4 V I R 0 MEN j 2� ENVIRONMENTAL HEALTH <br /> ItI=;tL7H L)i p, FITAreEtV�! PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp [:]Conditional Permit E] Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year ZU <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees Permit ID#: 0000460 <br /> State ID#: 39-0120-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000120 <br /> Site Name: CANTON LABOR CAMP 39-120 Location: 13631 N HURD RD, LODI <br /> Operator: CANTON,ANTHONY <br /> Mailing Address: 1231 MIDVALE, LODI CA 95240-0505 Facility Phone#:(209)334-9590 <br /> Legal Owner: CANTON,ANTHONY New Owner? ❑Yes ❑ No <br /> Owner Address: 1231 MIDVALE, LODI CA 95240-0505 Owner Phone#:(209)334-9590 <br /> Community Facilities Provided byCamp: Community Kitchen? ❑ Yes No <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to bg Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from 1 / ( / 17 to i Z S / L(/_ <br /> _ 7 Crop <br /> SF Dwellings �_ from _/_/ to Crop <br /> Crop <br /> Apartments F7 <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3 6s <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 /> El Inactive Require a PUBLIC WATER SYSTEM Permit <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 /> +s,-,--� Fee Schedule i 5 ,y <br /> ❑ Permanent Camp Annual Permit Fel $15-0+ Number of Employees @$,L2-15'0 each=$ <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> El Transfer of Ownership <br /> $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees <br /> @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ j S. C7V <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 � r/n A� V �� � jY,�� ❑ <br /> (Please PRINT or TYPE) Title Partnership <br /> Address <br /> a / ��Z7fG El Corporation c� <br /> �( c L,G� �/ CtG, Phone <br /> Applicant SignatureDate of Application <br /> Amount Paid '--V�-te of Payment Payment Type ChecktReceipt# Received By Account ID <br /> 3 1 S— f /'--2 U / k ! G iz-- I /_ 0000453 <br /> Facility ID Program Record ID PIE CJ Assigned to PWS ID <br /> FA0000454 PR0270120 2765 6219-DUNCAN WA0515730 <br /> Report#:7066 <br /> Application Printed:10/20/2016 <br />