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JOAQUIN COUNTY o PUDLIC MEAL ER*IICI_.S PAYMENT <br /> ENtiIRONMENTAL HEALTH Divi510N RECEIVED <br /> 304 E WEBER AwENuE o THIRD FLOOR• STOCKTON. CA 95202 <br /> 209/468-320 DEC z A n j� 1997 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY <br /> PERMIT TO�JFEftATE PUBLIC HEALTH SERVICES <br /> cMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTAL HEALTH DIVISION <br /> _\Nva Canap conditional Permit L_J AHUaal Perink For C:ahendar Year 199 <br /> ,_i A uteaded Psi ulk Li Multiple Years Wermanent housing t-autp►on#) Date Approved I <br /> C6auge at Operator __t_lb~of Owner lilacs MaUed: <br /> _t'�ea:tge ol'OpetxtorAddteas _ t:hat�te ol'(iwtterAddress t lPermito ei0046q <br /> _AddhionW Employees �C'amp!D 4 39-1201 <br /> Please Note any C'wrecdms or Changes in FodBlv'opemloriOwxer Inforaangon directty an this form <br /> Stte Name: LUNA LABOR C,41vfP 39-120 Location: 13631 N HURD RD <br /> L.-----_----------------------------_-----_-•----------- .----------------_....------------------ ----------------- -•- ------------------------- -------_._..... ---- - -----------------I <br /> i I <br /> Operator: YAMAUCHI,YOSHIYE _ — a ODI <br /> I Mailing Address: 1300 VISTA DR.LODI, CA 95242 Facility. Phone#: 209-368-2403 <br /> Legal Owner: YAMAUCHI,Y OSHIYE kdT ❑Ye. i�Nq i <br /> Owner Address: 1500 VISTA DR,LODI CA 95242 towner Phone#: 209-368-2403 <br /> 1.------------- - — — --- -- — <br /> Community Facilities Provided by Camp: Community Kitchen: it Yes No <br /> Men: Number of Toilets — Number of Showers Number of Lavatories <br /> Women:Number of Toilets Number of Showers Number of Lavatories <br /> :Iouslue Accomwilatious to be Utilized this Year: <br /> ^u dins Emplotiees td IFanploseea <br /> Dortultories: Owner Owned MARY _ <br /> SF ihveiilugs _ _ Owner Owned RR Cars <br /> Apartments _ MWRV Spaces <br /> ToiAL of Both COLUMNS <br /> occuu Dates: <br /> t om ' ! t /�,-tt5 to rota Number of Days to be used this caleader Year <br /> from—/T/ to —/ / Crop --- Total Dryys Occupied by:3 or stere Employees <br /> ------ <br /> —— --—— Note: Ca#*j xcirptai oy r3 or more rasp eve v fir 60 or more&Ws usurer <br /> e/turc a P*Mc l,'esterSy"em Permit. <br /> (] ID><CEIVB Irntxrrtunt: In order to orOteCt your land u,e stain .rfcama+vi!l not be timed th_rs vea r btr?Is inteAWMfor arse fit tete jktmre Geek this Boz and return <br /> My appNr4 m <br /> Fee Schedule <br /> F-1 Permanent Coin Annual Permit 535.00+Numbpr of Fmploveea n$13.00 each=S <br /> Urcliard Camp Perinit•Fee=$9115.00 <br /> IJ Transfer ofOwnershlp=$20.00 $ <br /> Permit Amendment=$20.00- Number of Additional Employees A$12.00 each=$ <br /> Late Appfication Fee$70.00+Number of Etnploveee n$24.00 each $ — <br /> Fee must be submitted with Application TOTAL FEE DUE: IS I <br /> PP <br /> REvnT ToT.4i FEE As CALCULAWD AaONT IN THE F;vCLo,veD self-addressed ENZrELOPT,. %f4KF CHHCKT R,ti 4BLE To: PINWEI <br /> Applicant agrees to all necessary Inspections Incident to Issuance of a PERmrr To OPERml. Applicant agrees that this project(camp)shall be <br /> operated and maintained in a, .ordance with the applicable provisions of the Emmoycn frousma ACT,Chapter 1,Part 1,Division 13 of the Health <br /> andSafi.P Cody and chapter 1.Subchapter 3,Title 2.5,California Code ofReguladonss. <br /> Applicant Nante(please prtw ortype) `IOJ��yC` t t�j�'t��j( i�,1 Title <br /> Address 1.. �J ,' J �1 Phone <br /> Applicant Signature L' . s'. %".l t.� Date of Application ! _ <br /> .f Amount ( Amount Paid!i Date ni Payment-�— Payment Type I ChookiRoosipt i Roosived By <br /> Employeeak 0843 Acd 0000453 Fac 1D: OOC454 RR s: 270120 PWS IDS P1E: 2755 ` <br />