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r .juin County-Environmental Health De ft Y 4� "Vr 1868 nzelton Avenue-Stockton CA 95205-Phone-l&-4f.-3420 c�I APPLICATION SAN J0,4 e 2a�9 ENVIRONMENTAL HEALTH H FNS/ROUINCO EMPLOYEE HOUSING ORPERMIT TO LABOR CAMP �CTATE yOF'°gR MFN ry ❑ New Camp ❑Conditional Permit ❑ multiple Years(Permanent Ilousing Camps only) ❑Annual Permit for Calendar Year T ❑ Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#: 0000460 *Additional Employees State ID#: 39-0120-EH EH ID#: 39000120 Please Note any Corrections or Changes in Facility/Operator Information directly on this form Site Name: CANTON LABOR CAMP 39-120 Location: 13631 N HURD RD, LODI Operator: CANTON,ANTHONY Mailing Address: 2485 CENTRAL PARK DR, LODI CA 95242 Facility Phone#:(209)986-5341 Legal Owner: CANTON,ANTHONY New Ownrr 7 ❑Yes _ No Owner Address: 2485 CENTRAL PARK DR,LODI CA 95242 Owner Phone#:(209)986-5341 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: Occupancy Dates: Buil ins Eml)loyees Dormitories from /_/?to_/_/_Q Crop SF Dwellings from _/_/ to Crop Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: VV MI-I/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year 7 � Reouire a PUBLIC WATER SYSTEM Permit ❑Inactive Important: 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 v ' K"'ermanent Camp Annual Permit Fet $50.00+ Number of Employees A— @$15.00 each=$ 2 ❑ Transfer of Ownership /6'0:` '0'9M i r jf'_F $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees _ @$30.00 each=$ Fee must be submitted with Application Q o TOTAL FEE DUE$ sr Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope Q p o MAKE CHECKS PAYABLE to EHD / Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project (cam� shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT, Chapter 1, Part 1, Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name Ay C Title ® ❑ Partnership (Please PRINT or TYPE) n ,cl p q PhE3 Corporation Address # 7 J C.�iS/T�i� L /i�R� 6/!1 / z .Z onerQ p9) Applicant Signature Date of Application / Amount Paid Dat of Payment Payment Type Chec eceipt# Received Account ID Z 0000453 Facility 16 Program Record ID PIE Assigned to PWS ID FA0000454 PR0270120 2765 9819-BENIAMINE WA0515730 /ND 310-7 9 to Report#:7066 Application Printed:1/14/2019