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q Joaquin County-Environmental Health Depa !nt PAYMENT <br /> 60 Main Street"-Stockton CA 95202-Phone: 20. 3-3420 RECEIVED <br /> - _- ; �qn� <br /> LJ E- <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing 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 <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 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 —L/--L/ 1�1i? to /,Aq-X/ !? 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 Fe( $35.00+ Number of Employees @$12.00 each <br /> ❑ Orchard Camp Permit Fee $95.00=$ <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 TOTAL FEE DUE$ a) (2 <br /> b <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EIID <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 Safery Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name }j h� � �a-�p Title /� E] Partnership <br /> --ate= -1�-\r",I1�=.�' <br /> (Please PRINT or TYPE) —r ❑Corporation <br /> Address �����,yG�NI�-� Phonen� <br /> Applicant Signature Date of Application <br /> Amount Paid Date Payment Payment Type hec Receipt# Received By Account ID <br /> (a 7 ✓ 0000453 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0000454 PR0270120 2755 yy2089J -S`O7 OD N/A <br /> Report#:7066.rot Application Printed:10/18/2007 <br />