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SAN .IOAQUIN COUNTY • PUBLIC HEALTH SERVICES ENVIRONMENTAL. HEALTH DIVISION 304 E WEBER AVENUE • THIRD FLOOR • STOCKTON CA 95202 • Phone: 209/468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑Annual Permit For Calendar Year ❑Amended Permit ❑Multiple Years(Permanent Housing Camps only) ate A roved • Change of0perntor *Change ofOwner )ate Mailed: • Mnnge of0perntor Address • Change of Owner Address emit tt 000460 ID# 39000120 • Additional Employees am- � Please Note any Corrections or Chm ac In Faclltl iU eralor/Owner In ormalton directly on this form. Site Name: CANTON LABOR CAMP 39-120 Location: 1363 N HURD RD Operator: CANTON,ANTHONY - - - - ------------------------------------------------------------ ------------------------------------------------------------------------------- ------------------------------------ Mailing Address: 1029 S CHURCH, LODI CA 95240 Facility Phone#: 209-334-9590 —-- -- ---—-- --- —-._.....------------ -----------------------—- -------— -------- ------_—_— ----— Legal Owner: CANTON,ANTHONY ew Owner ❑Yes ❑Nd Owner Address: 1029 S CI LURCH, LODI CA 95240 Owner Phone#: Community Facilities Provided by Camp: Community Kitchen: D Yes D No Men: Number of Toilets Number of ShowersNumber of Lavatories Women: Number of Tollets Number of Shower Number of Lavatories Housine Accommodations to be Utilized this Year: B»OdYr[s Employees Buildin¢s Employees Owner Owned MHIRV _ Dormitories. - - Owner Owned RR Car SF Dwellings Apartments MH/RV Spaces TOTAL of Both COLuMNs F_ Occupancy Dates: to I / / Crop Total Number of Days to be used this Calendar Year from�_l� -r"7 _ Total Days Occupied by 23 or more Employees _ Mom—/_/—is——/— Crop_ Note: Camps occupied by 2J or snore employees for 60 or niort days a year require a PmbNc Wafer.System Perm& ❑ Inactive ' In order to protect your land use status,if camp ml/not be used this year but lslntemtledfar Ise in tie,jirium,Clieck this Box and return t1us appltcdloft Fee Schedule ❑ Permanent Camp Annual Permit$;35.00+Nnmber of Employees A__512.00 each m$ ❑ Orchard Camp Permit Fee=$95.00=$ ❑ Transfer of Ownership=$20.00=S _ ❑ Permit Amendment=$20.00+Number of Additional Employees tt$12.00 each=$L1 Late Late Application Fee$70.00+Number of Employees_ @$24.00 each Fee must be submitted with Application TOTAL FEE DUE: e RF.MTr TOTAi,FEE AS CALCM ATED ABOVE IN TLfE RNc1.OSF,D self-addressed ENVELOPE.'jVfAATt CIRTOMPAY.411LIt TO: PIIS/F,IIDNOW v 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 Health and Safely Code and Chapter 1,Subehapt 3,Tide 5,Callfiirnia Code ofRegulations. Applicant Name Title ❑Partnership fership ❑Corporation (Plrast Pfi1N1 or TSPLhRAd _Iress Ph �=-�— Applicant Signature - < Date of Application= _ ProB ram Recor� 0120 Facility ID# 0 Account 1Dt1 0000453 krnmt_Pal�-- Da o(– t t T _ea t# fired BY� 1 o _99 _ 31G5 -'?- I Employee t. Acct#: F c ID: PR ti: PWS IDX: P/E -- —