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Stf iquin County-Environmental Health Departm ,.,� <br /> 600 E. n Street-Stockton CA 95202-Phone: 209-4t A0 PAY <br /> REC;E V <br /> APPLICATION NOV <br /> ENVIRONMENTAL HEALTH �y <br /> PERMIT TO OPERATE TY <br /> EMPLOYEE HOUSING OR LABOR CAMP SAN�QAQUIN <br /> ,/� ftMf�`. A <br /> F1 New Camp E] ,� <br /> Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit 11i1`i <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 0000460 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this I Camp 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 by Camp: Community Kitchen 7 ❑ 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 O from / / /0 to iZ 131 /C Crop <br /> SF Dwellings ( from _/_/ to /_/ Crop <br /> Apartments 13 <br /> Owner Owned MH/RV p Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars 0 Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces O 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 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 <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name Title ❑Partnership <br /> PP 'CN��f'l SLI C��� nLAID4C p <br /> (Please PRINT or TYPE) NN ,Tr ❑Corporation <br /> Address 1 IPA Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of yment Payment Type Check/Reoaipt# Received By Account ID <br /> \\, f O� s 4 s C 1 nr 0000453 <br /> Facility ID Program f Record ID P/E oAssigned to PWS ID <br /> FA0000454 PR0270120 2765 8987-SANGALANG WA0515730 <br /> —11 <br /> Reoort#:7066.rot /h _111­199<$S,31j Application Printed:10/14/2009 <br />