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San,loaquin County-Environmental Health Department r 304 E W Avenue-Third Floor-Stockton CA 95202-F e: 209-468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar YearaW ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit 1D#: 0000460 Please Note any Corrections at-Changes in Facility/Operator ht/brmation directly on this Camp ID#: 39000120 Site Name: CANTON LABOR CAMP 39-120 Location: 13631 N HURD RD,LODI Operator: CANTON,ANTHONY Mailing Address: 1029 S CHURCH, LODI CA 95240 Facility Phone#:(209)334-9590 Legal Owner: CANTON,ANTHONY New Owner? ❑Yes No �] Owner Address: 1029 S CHURCH, LODI CA 95240 Owner Phone#:(209)334-9590 Community Facilities Provided by Camp: Community Kitchen: LJ Yes NLJ 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 from/ /-0toQ/jL/ Crop Dormitories from_/_/_to_/_/_Crolr SF Dwellings Apartments Total Number of Days to be used this Calendar Year_ Owner Owned MH/RV Total Days Occupied by 25 or more Employees Owner Owned RR Cars Note: MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year TOTALS 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 n ❑Permanent Camp Annual Permit Fee: $35.00+ Number of Employees_ @ $12.00 each=S- r-1 !❑ Orchard Camp Permit Fee: $95.00=$ nn Transfer of Ownership: $20.00=$ El Late Amendment Fee: $20.00+ Number of Agional Employees @ $12.00 each=$_ bale Application Fee: $70.00+ Number of Employees @$24.00 each=$ Fee must beuQmitted with Application TOTAL,FEE DIiF,: $ � Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope MAKE CHECKS PAYABLE TO: PHS-EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that thk project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACI',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 r El Partnership (Please PRINT or TYPE) C El Corporation Address �j �l - LnA ` ` D Phone v��j) Applicant Signature �� Date of Application ) Amount Paid Date'ot Payment Payment Type hec Receipt# Received By Account ID J p D ✓ 0000453 Facility ID Program Record ID PIE Assigned to PWS ID 0000454 0270120 2755 1522-VAN BUREN 0000460 Report#:7066.rot Application Printed:11/20/2002