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PAYMENT <br /> Joaquin County-Environmental Health Departm, ;t <br /> R1ECEpVF![) <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209468-3420 DEC 0 5 2013 <br /> APPLICATION <br /> MENTAL <br /> 1WALL H DE PARTILIE <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP Z-6 I <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) �nnual Permit for Calendar Year <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0000460 <br /> *Additional Employees <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 a No <br /> Owner Address: 1231 MIDVALE, LODI CA 95240-0505 Owner Phone#:(209)334-9590 <br /> Community Facilities Provided by Camp: 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 be Utilized this Year: Occupancy Dates: <br /> Buildings Employee s <br /> Dormitories from I l I l )-ei 10 1 213 11 2­�' t�I-I Crop V+4-t G"A—S! <br /> SF Dwellings I I _ from —/—/—to—/ Crop <br /> Apartments I 'S t <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: S <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> Camps occupied by 25 or more Employees for 60 or more days in a year <br /> TOTALS 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 <br /> Permanent Camp Annual Permit Fet $35.00+ Number of Employees @$12.00 each=$ <br /> Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ <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 and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name r � r / t Title ❑ Partnership <br /> y <br /> (Please PRINT or TYPE) �—T �a, I �� <br /> r � ` ` I ❑Corporation <br /> Address ✓ I, ` Phone_ <br /> Applicant Signature Date of Application <br /> Amount Paid a of Payment Payment Type Che eceipt# Received By Account ID <br /> 0000453 <br /> 7FAFacility ID Program Record ID PIE Assigned to PWS ID <br /> 0000454 PR0270120 2765 8987-SANGALANG WA0515730 <br /> Report#:7066 Application Printed:10/17/2013 <br />