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oaquin County-Environmental Health Depart <br /> 304 E Weber ,venue-Third Floor-Stockton CA 95202-Phon. _09-468-3420tt <br /> APPLICATIONENVIRONMENTAL HEALTHPERMIT TO OPERATEEMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Ca <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 Chan/;es in Facility/Operator/!formation directly on this Camp ID#: <br /> Site Name: CATON,DARRYL J Location: 15635 S STEINEGUL RD,ESCALON <br /> Operator: CATON,DARRYL J 0 <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: LJYesNLJ <br /> Men. Nwuiici Uf ToiictS _ Number of Showers Numbcr of Lacatores <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 �O <br /> Permanent Camp Annual Permit Fee: $35.00+ Number of Employees —45' @ $12.00 each=S�QD. <br /> ❑ Orchard Camp Permit Fee: $95.00=$ <br /> n(� Transfer of Ownership: $20.00=$ <br /> ❑ Permit Amendment Fee: $20.00+ Number of Ai'iTRional Employees @ $12.00 each=S_ <br /> Late Application Fee: $70.00+ Number of Employees @$24.00 each=S <br /> Fee must be'"matted with Application Q 0 <br /> TOTAL FEE DUE: S to <br /> Rem&TOTAL FEE as CALCULATED ABOVE in ilie ENCLOSED Self-Addressed Ei velope <br /> MAKE CHECKS PAYABLE TO: PHS-EHD <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 ris r v Title 0(� p r ❑Partnership <br /> (Please PRINT or TYPE) 0 Corporation <br /> 3oZ <br /> Address () Phone <br /> Applicant Signature / - Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0003037 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> 0003460 0200071 2011 9374-GODINHO 0007247 <br /> Report#:7066.rot Application Printed:11/20/2002 <br />