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aquin County-Environmental Health Depart <br /> 600"L.Main Street-Stockton CA 95202-Phone: 209-4uu-x420 :. � 201+1 <br /> 13F C 1 <br /> •r <br /> SAS JO R WgAE rSAL <br /> APPLICATION EhM pgB�tEMV <br /> ENVIRONMENTAL HEALTH HEpLT+of <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar YeaQ <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#: 39000120 <br /> EH ID#: 39000120 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on thisfor•m. <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 /> Communitv Facilities Provided by Camp: 0,,r//4 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: Occupanev Dates: <br /> Buildings Emplovees <br /> Dormitories from / / /Zo 17-to1z/3/ZO/Z Crop V a n 01&(.S <br /> SF Dwellings f from _/_/ to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3 6j S <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS Camps Camps occupied by 25 or more Employees for 60 or more days in a year <br /> I 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 ►,J 27q-77 2 <br /> ruf Permanent Camp Annual Permit Fen $35.00+ Number of Employees I @$12.00 each=$ �7 <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 <br /> and Safety Corte and Chapter 1,Subchapter 3,Title 25,California Corte of Regulations. <br /> Applicant Name Title l 1tA.1 rV 1 El Partnersh ip <br /> (Please PRINT or TYPE) STK )SIT <br /> 7 1 ❑Corporation <br /> pp f - <br /> Address ,�I� 6' � f C)/.� C <br /> � �j__ 11.: Phone '�� <br /> Applicant Signature _492Date of Application <br /> Amount Paid 501.,of Payment Payment Type Check/ ceipt# Received By Account ID <br /> 0000453 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0000454 PR0270120 2765 000--SANGALANG WA0515730 <br /> Report#:7066.rpt Date t = t 2 Application Printed:10/25/2011 <br />