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M <br /> San Joaquin County-Public health Services <br /> r —~ Environmental Health Division <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP n <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) 0 Annual Permit for Calendar Year o <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees Permit ID#: ��3900012O <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this <br /> Camp ID#: <br /> Site Name: CANTON LABOR CAMP 39-120 Location: 13631 N HURD RD,LODI <br /> Operator: CANTON,ANTHONY <br /> Mailing Address: 1029 S CHURCH,LODI CA 95240 Facility Phone#:(209)334-9590 <br /> New Owner Y ❑Yes E]No <br /> Legal Owner: CANTON,ANTHONY <br /> Owner Address: 1029 S CHURCH,LODI CA 95240 Owner Phone#:(209)334-9590 <br /> Community Facilities Provided by Camp: Community Kitchen: YesN Number of lavatories <br /> Men: Number of Toilets Number of Showers <br /> Women: Number of Toilets Number of Showers Number of Lavatories _ <br /> Housing Accommodations to be Utilized this Year: Occunancy Dates: <br /> from /O/b2 to l�l3 /O�Crop _ <br /> Building Employees from—/- _ <br /> Dormitories <br /> SF Dwellings Total Number of Days to be used this Calendar Year_ <br /> Apartments Total Days Occupied by 25 or more Employees <br /> Owner Owned MH/RV Note: <br /> Owner Owned RR Cars <br /> MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year <br /> TOTALS require a Public Water System Permit. <br /> O U <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 s @ $12.00 each=� e 00r_ <br /> ❑Permanent Camp Annual Permit Fee: $35.00+ Number of Employee <br /> El Transfer <br /> Camp Permit Fee: $95.00=S <br /> Transfer of Ownership: $20.00=S <br /> u <br /> Permit Amendment Fee: $20.00+ Number of A Tonal Employees C $12.00 each=$ <br /> S_ <br /> 13 $24.00 each=S <br /> Late Application Fee: $70.00+ Number of Employees <br /> Fee must be LImitted with Application TOTAL FEE DUE: $ <br /> f.. <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope <br /> MAKE CHECKS PAYABLE TO: PHS-EHD <br /> I.r tl f <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(�a�p�)1 shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 131J5fEilfF;ia EVii(dkh <br /> and Safei)v Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations, 1I�/Flt tRJTr t td Ar ;. /; f <br /> Title ald f3 °,1Partnership <br /> Applicant Namc ❑Corporation <br /> (Please PRINT or TYPE) <br /> n Phone "- <br /> Address <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0000453 <br /> $ 143. 00 /a-/I/D <br /> PIE Assigned to PWS ID <br /> Faculty ID Program Record ID 0000460 <br /> 0000454 0270120 2755 1522-VAN BUREN <br /> �f I I�O� Q/���^ Application Printed:11/19/01 <br /> Reoort#.7066.rot H`� vel `� <br />