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�ir1it AN JOAQUIN COUNTY • PUBLIC HEALTH .VICES ENVIRONMENTAL HEALTH DIVISION �2- 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 Approved • Change of Operator *Change of Owner ate Mulled- • Change of Operator Address • Change of Owner Address ermlt# 000460 • Additional Employees am ID# 39000120 Please Note any Corrections or C es in F /O erator/Owner In ormatton direca 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 New Owner ❑Yes ❑No Owner Address: 1029 S CHURCH,LODI CA 95240 Owner Phone#: Community Facilities Provided by Camp: 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: Bulldlnas Employees Buildings Employees Dormitories: Owner Owned MH/RV SF Dwellings Owner Owned RR Cars Apartments MH/RV Spaces TOTAL of Both COLUMNS L� Occupancy Dates: ` from i U to I,�1 /�p Crop Total Number of Days to be used this Calendar Year prom to yyy"`777 /— — Total Days Occupied by 23 or more Employees —— —— Note: Camps occupied by 23 or more emrploVees for 60 or more days a year require a Public Wafer Systeme Per=& ❑ Inactive ImsDORaet. In order to protect your land use status,if camp will not be umd this year but is/ntexded far use in Ike fig um,CAeek this Box and return this app&a Um Fee Schedule ❑ Permanent Camp Annual Permit$35.00+Number of EmployeesCl $12.00 each=$ ❑ Orchard Camp Permit Fee=$95.00=$ ❑ Transfer of Ownership=$20.00=$ ❑ Permit Amendment=$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 DUE: REMIT TOTAL FEE AS CALCULATED ABOVE IN THE ENCLOSED self-addressed ENVELOPE.jVAKE CHECKS PAYABLE TO: PHS/EHD Applicant agrees to all necessary inspections incident to issuance of a PFimm To OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE Housuvc ACT,Chapter 1,Part 1,Division 13 of the Health and Safety Code and Chapter 1,subchapt 3,Title ,California Cods ofRegulations. . Applicant Name Title ❑P ershlp ❑Corporation (Please PW.T or 7YPE) A dress Ph ow Applicant Signature Date of Application .� Program Recor 0120 Facility 11)#_dAccount ED# 0000453 Amount Paid Datc o t t Type edBy 6 n /-:' io9`I Employee P. Acct#: Fort ID: PR#: PWS IP/Ea