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JOAQUIN COUNTY a PUBLIC HEALTH S1 CES <br /> ENVIRONMENTAL HEALTH DIVISION h <br /> 304 E WEBER AVENUE a THIRD FLOOR a STOCKTON CA 95202 a Phone: 209/468-3420 <br /> APPLICATION � <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPEPATE <br /> ,MPLOYEE HOUSING OR LABOR CA41P <br /> 0 New Camp ❑Condltional Permit ❑Annual Permit For Calendar Year <br /> 11 Amended Permit ❑Multiule Years(Permanent IIonslne Camps onto bate )proared <br /> • Change of Operator •Change of Owuer ute'4lutied: <br /> • Change of Operator Address . Change of(honer Address ermlt# 000460 <br /> • Additional Employees :Caly IDR 3?000120 <br /> Please Note anv C'nrrec{la o n ER /Op s In}7►rmniton directly on this form. <br /> 1 Site Name: Location: 1363 N HURD RD I <br /> Operator: <br /> blallln Addretg: 1' /� � - <br /> g actlity Phone#: ? <br /> —.- <br /> Y <br /> 111 _.__.--------- <br /> rr <br /> Owaer FLvgal Owner: <br /> es uN� <br /> -w — - - ------ <br /> owner Aaaress: '`: " c I �, �,� r Owner Phone rt. <br /> i olunwuity Fad&les Provided by Cam Community Kitchen: D Ye: O No <br /> Men: Number of Toilets Number of Site Number ofLwvatortes <br /> Women:Number of Tenets Number of Shower Number of Lavatories <br /> I:uusuia A"maimodations to be Utillied this Year. <br /> Bell dfnas Employees Ball �a <br /> ]Dormitories: Owner corned 14i1i,RV <br /> 8F Dwellinas ---- Owner Owned RR Caws <br /> Apartments ---- MRV Spaces <br /> -- TOTAL Ol Both COLvWa <br /> Occu <br /> from / to /�/ 1 C4vp Total Number of Days to be used this Calendar Year I J <br /> firom r_ _(_/ to�/4j�l Crop Tot Lays Occupied by lS or mom r.mpioyeos <br /> —TT �[ p dg: amps occufxea ay.'3 ar rear a uwisiary see Jvr iB or worn drys a y�cwr <br /> recur#a Pnbde{i"alerA Timm Penson <br /> 0 Inactive .rm"r*w. in order to protect your land use status.ilcam_n w:u not be used this year bin is bdesder7Jdr use in ihe•jWure. Geek this Box and return <br /> - .ami►. <br /> PAYMENT it ee schedule <br /> RECEIVED, Camp Annual Permit$35.00+Number of Employees `' 1 $1100 each-S <br /> DEC 1 1998 � u Orchard Camp Permits Fee=S95.00—S _ <br /> UV i r:tnsier o[Ownerst►Ip=P20.00=$ <br /> SAN JOAQUIN COUNTY Permit Amendment=$20.00+Number of Additional 2.1o'yees __ (eU$12.00 each=)i <br /> PUBLIC HEALTH SERVICES 9 bate Application Fee S'70.00+Number of Employees 4*$+24.00 each=$ <br /> ENVIRONMENTAL.HEALTH DIVISION PP p — <br /> Fee must be submitted with Application T0T.4L FFF DUE: <br /> REMIT TOTAL FEE AS CALCULATED ABOVE IN THE BNCLOSUD wit-addressed ENVELOPE. AfAAw CkonwPAmeae M. l'HS/EHD <br /> Applicant agrees to all necessaryinspections incident to Issuance of a PERMrr TO OPERATE. Applicant agrees that this project.(camp)shall <br /> ht'operated and maintained in accordance With the applicable provisions of the EmmoYEE HOtr MO ACT.Chapter 1.Part 1.Division 13 of the <br /> Health and Safety Ca a and Chapter 1,Subchapter 1,Title 25,California Cade ofReguktdotu. <br /> Applicant Name 1 Title 0 Partnenhip 0 Corporation <br /> iPleart pRt7+fjor 77'PL1 • ri � � �_ I— •.� � �' / <br /> Address � �c i Phone <br /> Applicant Signature %` Date of Anniicatlon <br /> YrvRtam xec d IDH K l _- Facility ID# 000454- - Account JD# 000WJ <br /> fee Amount mount Paid Pate of Payment I Payment Type Check/ 0612t# RecajivAd By <br /> u <br /> Emp ys ;t. - ---- -At; PV v IDS: f/E: <br />