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PAYMENT n Joaquin County-Public Health Ser'* RECEI�/Ep Environmental Health Division 304 E Weber Avenue-Third Floor-Stockton CA 95202 -Phone: 209-468-34210w 9 APPLICATION AUUIN CpUNZY ENVIRONMENTAL HEALTH SAN JO AtIBSETHCfs PERMIT TO OPERATE ENV RONMENTALEpLTD VISION EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year ❑Amended Permit: 'Change or Operator 'Change or Owner 'Change or Operator Address 'Change or Owner Address 'Additional Employees Permit ID#: 0000460 Please Note cvry Corrections or Changes in Facility/Operator Information directly 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 T_ New Owner? ❑Yes ❑No Owner Address: 1029 S CHURCH,LODI CA 95240 Owner Phone#: (209)334-9590 Community Facilities Provided by Cama: Community Kitchen: Elyes 0 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: Buildires Employees from-/-L/'oj tot/�/bJCrop_ Dormitories from_/_/_to_/ / Crop_ SF Dwellings Apartments Total Number ofDays to be aced this Calendar Year Owner Owned MH/RV _ __ TotalDaysOccupledby25orname Empb}ees Owner Owned RR Cars _ Note: MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year TOTALS r� � require a Public Water System Permit. ❑ Inactive u Im rrortant: 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 C El Permanent Camp Annual Permit Fee: $35.00+ Number of Employees _J @ $1200 each= S� ❑ Orchard Camp Permit Fee: $95.00-S ❑ Transfer of Ownership: $20.00=s ❑ Permit Amendment Fee: $20.00+ Number of Additional Employees @ $12.00 each= s ❑ Late Application Fee: $70.00+ Number of Employees @ $24.00 each= S Fee must be submitted with Application TOTAL FEE DUE: S RemitTOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope MAKE CHECKS PAYABLE TO: PHS-EHD INV. OG 7Y,I Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT, Chapter 1, Part 1, Division 13 of th California Health and Safeiy\C�o'de and Chapter 1,Subchapter 3,Title 25,California Code of Regulatious I11(\A-ems1��-(�, ,,\-1 Title ( I ?s`> ❑C r Corporation,Applicant Namc I 11`�fil ❑Corporation (Please PRINT or TYPE) I ) \� ' Address �(i 1 �Yl �>,� 1� ^� t L+i)c� iT ;t� s r�T 1_�,�,�L Phone '�� _I Date of Application j6 Applicant Signature , Amount Paid gate of Payment Payment Type 7—Check eceipt# Received By Account ID 0000453 � 1'�3 r 1��-I-�� C�l�� - 3S�•'1 � Facility ID Program Record ID P/E Assigned to PWS ID 0000454 0270120 2755 L-5366-MEDINA 0000460 Application Printed:11/7100 Report 7066.rpt