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Joaquin County-Environmental Health Depar t <br /> 600 Is.Main Street-Stockton CA 95202-Phone: 209-4u6-3420 <br /> �I APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> ( PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent(lousing Camps only) ❑Annual 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#: 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 No <br /> Owner Address: 1231 MIDVALE, LODI CA 95240-0505 Owner Phone#:(209)334-9590 <br /> Community Facilities Provided by Cama: 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: Occu anc Vis: <br /> Buildings Employees <br /> Dormitories fr m / / ZdN to /Z/ S(/ ZAf1 Crop <br /> SF Dwellings f otn /_/ to_/_/ Crop <br /> Apartments 1 3 <br /> Owner Owned MH/RV Total er 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 /> TOTALSQ Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> El 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 Fe( $35.00+ Number of Employees a $12.00 each=$ <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 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 S4' ` <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 Cade and Chapter 1,Subcbapter 3,Title 25,California Co e of Regulations. <br /> Applicant Name Title � �i0 ❑ Partnership <br /> (Please PRINT or TYPE) 1 7V IF <br /> ❑Corporation <br /> Address ` Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment TypeChec ceipt# Received By Account ID <br /> 7*--)-2 p O b S& 11 0000453 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0000454 PR0270120 2765 8987-SANGALANG WA0515730 <br /> Report#:7066.rpt Application Printed:11/2/2010 <br />