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b�b <br /> SA �ndCOUNTYlCOUNTY • PUBLIC IIrAI,'ru SFRv L t _. <br /> _.NVIIIONN(rNTAL HEALTH DIVISION <br /> 304 E WFnISR AVENUE • TIMID FLOOR • STOCKTON CA 95202 Phone: 209/468-3420`� <br /> 523 APPLICATION: <br /> ' Tvlt� ENVIRONMENTAL HEALTH <br /> N <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> New Camp ❑Conditional Permit ❑Annual Permit For Calcudar Year <br /> ❑Amended 1' inil ❑Nlulfilk Years(Pern►nnew(lousing Camps only) bate A r troved <br /> • Change o Operator •Change of Owner Dale Mailed: <br /> • Change o Operator Address • Change of Owner Address Permit# <br /> • Add ition•I Employees Camp ID# <br /> ('lease Nol any Corrections or Chances in Fac'iliti mwfor/(honer/n oruratiott directly on this form. <br /> Site Namc Lj - Location: <br /> operator. _J f,�v i 5�s� � L <br /> Y�i !3 r� ro ---------------------------------------------------------- <br /> Mailing Address: � - Facilil 1'1 of a#• <br /> -..._.. - - --- ----- ----- ----------- ------ �--- - -' - = -`�3-1-15-b `t <br /> _..... .- .. __- _._ . <br /> Lc��I Olyncl': 1 <br /> b O( r Ncw(hence ��1'cs Nn <br /> ---------------- !1 <br /> - - -= - - - - ---- <br /> Oivner Address: 2zZ Olyna• Phonc It: <br /> Community Facilities Provided by Camp: Community Kilchen: Yes El <br /> Nlcn: Number of Toilets Number of Show ers { Number of I,avnlorics�_ <br /> Women: Numhcr ofToacts___ Number of Showers Number of Lavalorics <br /> Ilonsina Accommodations to be Utilized this Year: <br /> 1)uildines F,nmlol.c(s IAiildines ICundnrccs <br /> Dormitories: j Owner Uwned hall/Itl' <br /> SF Dwellings Owner Owned I(R Cars <br /> Apartments 11111/ltv Spaces <br /> TOTAL of Both COLUMNS � �J <br /> Occnn:ulcl, Dates: <br /> from L /Z 3 0,`, to Z / JrIG Crop Toul Number or Days to be used Ihit Calendar Year <br /> from�/ 11f7 l7 v <br /> Rrtal bays Occupied by 15 or more Employees <br /> to / /tX� Crop � �, Note: Ganges or('tg)irrl hY 15 or strove eruployecs far 60 or more da)s a l•cnr <br /> require a Public Water S►'stenr Permit. <br /> U 111.10 iVe hnPortaat: /it order to protect your lama use status•ifcamp will not be used this year but is intended for use in the future,Check this Box and rentrn <br /> this alvplirntion. <br /> Fee Schedule q <br /> Lt Permanent Camp Annual Permit $35.00+Number of F,mployces -13 _ $12.00 each= 9D I <br /> U Orchard Camp Permit Fee=$95.00=s <br /> U '1'r:utsl'cr of o► iicrship=$20.00=S <br /> U Nerrltil Atticntltttent=$20.00+Numbcr of Additional Employees R $12.00 cacti=$ <br /> U Lafe Application Fcc$70.00+Numbcr of Employees @$24.00 each=$ <br /> [;cc must be submitted with Application TOTAL FEE DUE: �s C1 1 <br /> RENIrr'l'OTAL Fee As CAI.(-nIXrr•.0,love.IN Tnr•.r:NCt.o.crn self-ad(h'c ed ENvr•.Lorr. AIAKr Cut..,mv/',n;urr.r ro: Pf IS/E,11I) <br /> Applicant agrees to all necessary inspections incident to issuance of a PFRMITTO OPERATIi. Applicant agrees that(his project(camp)shall <br /> Ile operated and maintained in accordance n'ilh the applicable provisions of the ENIPLOYFE uouSING ACr,Chapter I,fart I,Division 13 of fire <br /> Health and Safety Code and Chapter 1,Suhchapler 3.Title 25.California Cole of Regulations. <br /> Applicant Nanic LAW % ^��� ` Title I II'arinenhip f Wo{rpo(r�alion <br /> case PRINT or TIT/) Ad ress \ L Phone J Q 3 I—L \p D <br /> pplicant Signature Date of Application <br /> Program Record ID# Facility IDII � t Account ID# 4 J <br /> Amount Paid Dale of Pa ment Payment Tyve Check/Receipt 0 Recetved D <br /> ✓ -N 3 <br /> Employee#: Acct#: rac ID: PR q 1,6 <br /> O 7 ,1 PWS ID#: P/E: <br />