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Joaquin County-Environmental Health Depa ,nt PAY VE VT 304 E Webe, .avenue-Third Floor Stockton CA 95202-Phk. 209-468-3420 RFGlt/P:Cj APPLICATION UEU - ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) fi�Annual Permit for Calendar Yea�� ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: 0000460 Please Note any Corrections or Changes in Facility/Operator Information directly on this I 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 Cama: 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,l /-:31. Crop f 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 Fe $35.00+ Number of Employees I o� @$12.00 each=$ ❑ 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 DU , 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,Subchapter 3,Title 25,California Code of Regulations. Applicant Name Title La/�,a,(' ❑Partnership (Please PRINT or TYPE) ! m �'-�fI�N°" Corporation Address Address C PhoneL- Applicant Signature �, Date of Application Amount Paid Dat of Payment Payment Type Check/Receipt# Received By Account ID 0000453 17q Facility ID Program Record ID P/E Assigned to PWS ID FA0000454 PR0270120 2755 1522-VAN BUREN N/A Reoort#:7066.rot Application Printed: 10/29/2004