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S 'oaquin County-Environmental Health Departr ' PAYMENT <br /> 6001 Ain Street-Stockton CA 95202-Phone: 209-4 x420 RECEIVED <br /> 1.ik — Q 7 naEl <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN OCOUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL ENTAL <br /> HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP /��]� <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) X Annual Permit for Calendar Year 1//f'f <br /> ❑Amended Permit: *Change of Operator *Change of Owner ////������ ��7777�'—! <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 Camp ID#: 39000120 <br /> Site Name: CANTON LABOR CAMP 39-120 Location: 13631 N HURD RD, LODI <br /> Operator: CANTON,ANTHONY <br /> Mailing Address: 1729 LE BEC CT,LODI CA 95240-0419 Facility Phone#:(209)334-9590 <br /> Legal Owner: CANTON,ANTHONY New Owner? ❑Yes No <br /> Owner Address: 1729 LE BEC CT,LODI CA 95240-0419 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: Occupancy Dates: <br /> Buildings Employees A'4 <br /> Dormitories from =/ f / / Crop <br /> SF Dwellings from / / to_/_/ Crop <br /> Apartments 3(_ <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year Y <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 /> XPermanent 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 /> ca- <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 a., Title n ❑Partnership <br /> (Please PRINT or TYPE) � ❑Corporation <br /> Addressfflaq Phone <br /> Applicant Signature Date of Application <br /> Amount Paid ate of Payment Payment Type Check/ ceipt# Received By Account ID <br /> 0000453 <br /> Flo ci 63S — <br /> Facility ID Program Record ID P/ Assigned to PWS ID <br /> FA0000454 F1W.�a}pp 270120 55 1421 RA N/A <br /> 1300 <br /> Reoort#:7066.rot Dde Z ��� Application Printed:10/30/2008 <br />