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EECENED � �N O S oaquin County-Environmental Health Depar' t o 304 E Weber.- -nue-Third Floor-Stockton CA 95202-Phot.. 209-468-3420 DEC1 2006 31 JVIRDN Q�GC' OVN� APPLICATION MEIUT HEALTHP00\N&NlP1-� ENVIRONMENTAL HEALTH PERMIT/SERUI�ES SP ENv� 0 PPPERMIT TO OPERATE �N EMPLOYEE HOUSING OR LABOR CAMP ❑NgCamp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Perms for Calendar Year J ❑Amended Permit: 'Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employes Permit ID#: 0000460 Please Note any Corrections or Changes in Facility/Operator Information directly on thi. Camp ID#: 39000120 Site Name: CANTON LABOR CAMP 39-120 Location: 13631 N HURD RD,LODI Operator: CANTON,ANTHONY Mailing Address: 1729 LE BEC CT,LODI CA 95240-0419 Facility Phone#:(209)334-9590 Legal Owner: CANTON,ANTHONY New Owner? ❑Yes No Owner Address: 1729 LE BEC CT,LODI CA 95240-0419 Owner Phone#:(209)334-9590 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories from _/_/ to_/ / Crop SF Dwellings from _/_/ to_// Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive 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. Fee Schedule Permanent Camp Annual Permit Fee $35.00+ Number of Employees @$12.00 each=$. 12(2 ❑ Orchard Camp Permit Fee $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUPS Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and Safety Code and Chapter 1,Su chapter 3,Till 5,California Code ojRegulations. Title ❑ P Applicant Name � r�,G��' Partnershi (Please PRINT or TYPE) �-W ❑Corporation Address Phone , Applicant Signature Date of Application Amount Paid Date ofIftsFirlent Payment Type —G NKMeceipt# Received By Account ID `2 l` /� ✓ S 09 1 0000453 Facility ID Program Record ID PIE Assigned to PWS ID FA0000454 PR0270120 2755 1522-VAN BUREN N/A Report#:7066.rot Application Printed:10/23/2006