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oaquin County-Environmental Health Depar <br /> 304 E Webei ..venue Third Floor Stockton CA 95202 Phos. 09-468-3420 {PAYMENT <br /> RECEIVED <br /> APPLICATION SAN - 7 CUU3 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE SAN JOAQUIN COUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP PHBI M HEALTH Sf P,%1f7S <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) VO Annual Permit for Calendar Year <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 0007247 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this Camp ID#: <br /> Site Name: CATON,DARRYL J Location: 15635 S STEINEGUL RD, ESCALON <br /> Operator: CATON,DARRYL J <br /> Mailing Address: 15206 S STEINGUL RD, ESCALON CA 95320 Facility Phone#:(209)838-3181 <br /> Legal Owner: CATON,DARRYL J New Owner? ❑Yes ❑ No <br /> Owner Address: 15206 S STEINGUL RD, ESCALON CA 95320 Owner Phone#:(209)838-3181 <br /> Community Facilities Provided by Camp. Community Kitchen: EI Yes NJJ <br /> ;vice: Nwi uci Qf Tuilets _ ":uruberofShow.;rs Numbcrof"va.ores <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees from_/_/_to_/_/_Crop _ <br /> Dormitories from_/_/_to_/_/_Crop <br /> SF Dwellings Z <br /> Apartments Total Number of Days to be used this Calendar Year_ <br /> Owner Owned MH/RV Total Days Occupied by 25 or more Employees <br /> Owner Owned RR Cars Note: <br /> MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year <br /> TOTALS require a Public Water System Permit. <br /> ❑ Inactive <br /> 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. <br /> Fee Schedule �Q <br /> ❑Permanent Camp Annual Permit Fee: $35.00+ Number of Employees -5 @ $12.00 each=$___(a0. <br /> ❑ Orchard Camp Permit Fee: $95.00=$ <br /> nn Transfer of Ownership: $20.00=$ <br /> ❑ Permit Amendment Fee: $20.00+ Number of Agional Employees @ $12.00 each=$_ <br /> Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must beuimitted with Application <br /> TOTAL FEE DUE: $ <br /> n@rrdi TOTAL FEE as,CALCULATED ABOVE Ili iue EINCLOSED Se i-Addrtsbed Envelope � �^ �,/1 <br /> MAKE CHECKS PAYABLE TO: PHS-EHD p Il t P <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name Title D W n.e lr ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address El3,9-0 Phone b F- 5 <br /> Applicant Signature I Date of Application �oZ' —Qz <br /> Amount Paid Date of Payment Payment Type hec-fZeceipt# Received By Account ID <br /> `$B� ' /n 0003037 <br /> 5•D o �/ <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> 0003460 0200071 2011 9374-GODINHO 0007247 <br /> Report#:7066.rpt Application Printed:11/20/2002 <br />