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PAYM�IED <br /> S. .oaquin County-Environmental Health Departs RECE <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 <br /> DEC U L 1. <br /> SA.N 30,QUVH <br /> APPLICATION ENS "kRTUEST <br /> ENVIRONMENTAL HEALTH HEALTH DE <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 YealQa <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 this form. <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 Zf 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 Employees <br /> Dormitories from _/_/ to_/_/ Crop <br /> SF Dwellings from _/ / to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> 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 Fei $35.00+ Number of Employees _ a $12.00 each=$ ' 0 <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 a $12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees a $24.00 each=$ <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 Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name �� ��)� Title r EJ Partnership <br /> (Please PRINT or TYPE) <br /> ❑ Corporation <br /> Addresst Phone _ U <br /> - :60 - <br /> Applicant Signature Date of Application <br /> Amount Paid DtmRe <br /> t1D <br /> Paym!P/E=Assigned <br /> Received By Account ID <br /> 0000453 <br /> Facility ID Prord PWS ID <br /> FA0000454 PR0270120 2765 8987-SANGALANG WA0515730 <br /> ��—_ Annlirafinn Print-d'10/25/2011 <br />