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A.,g, 19. 2 1 8:52AM So a Q u i C o u n No. 0994 1 <br /> i Joaquin County-Environmental Health Doportme <br /> t5 <br /> &Main Street-Stockton CA 93202-Phone: 209-469'MO <br /> APPLICATION <br /> ErgVIRONMENT,4LRX&LTH <br /> PERMIT TO OPERATE <br /> 1NPLQYEJE HOUSING OR WOR CAMP <br /> Cl New Camp ❑Conditional Permit [7 Mulnple Years 0l?ernaernt tionatag Camps only) ❑Annual?trait ror Calwdar liar_ <br /> �AraendrdPeeeair: -Chaa9eof0ptratur 'ChangeotOwaat <br /> 'Charge of 0perarur AJ&*4& 'Chani-of Owner Addren <br /> -Adcktioaal 8npleyaw <br /> ermit 1D tt: <br /> Nettie Note any Corrections or Changes in Facili�a'Ope-Wor 1rf armr.110n XreoMl on A& IMP m 0: <br /> Site Naso 114-13 �, D��5 (�j <br /> Operator: <br /> MaWag Address: Z _33�> Facility Rove M: 3.G_'�,- I 7 <br /> 140 Owner: kf K ` _ N"Owaer? ❑Yes ❑ No <br /> t7svnrr AeldreaaDer Phone d: <br /> C I es Pro ' d : Comtnunily Kitchen.? [3 Yee [a NL' <br /> Mn; Number of Toilets Number of Showers Tombs-of La.uories <br /> Women: Number of Toilcis Number of Mowers Nwribrr of Lavatories <br /> Housise ACcommodati4fioa ke i�tilised this!'ear: Ckesaolmv nates: <br /> Buildiags F�ttu tilt ems <br /> fx;rmiu ries _ 3:am / to 1_/ Crop <br /> 9F Dwdlloys —AL — � from __l_I to�lI Crop <br /> Aparanents <br /> Owair Owned MH/RV ��- Total t`l=ber ofbays to be used cfis Calendar Peer• <br /> Owner Owned RR CArs "— — Totai Days Occupies by 21 or toore Employees: -- -- <br /> M'H/AV Spaces Note <br /> TOTALS 'Camps occupied by 25 or mune Employers for 60 or more days in a year <br /> l J Require it PUBLIC NATER 3YSTF-M Permit <br /> ❑inactive <br /> Ikon O tanft In order to promd your land use latus,if—up will twt be rid dw yew but it iniendad for use in the future,Cnei k ilii,Box sM:,Lcwro tbis applimuon <br /> Fee ehodaie <br /> Pemwntrit Camp Annuai Peraut ret 33500+ Number of Froployees _ 512.00 each s S <br /> ❑ OrChUd Camp?orsnit FCC $95.00—S <br /> ❑ Tri sferof0irnership $20.D0=S <br /> ❑ Pcrmaaen_Ameadw&itFee 520.00+ NtmibcrofAdditional'Emp:oyees (g$I2.00each=S,^ <br /> ❑ L atC Applieatioo Fac $70,00+ Numba of"loye m r ;ka$24.00 each-$ <br /> Fee must he submitted with Applicat" TOTAL AEE DLI S , 0 <br /> Remit'170TAL FEL as CALL DILATED AXOVE In the ENCLOSED Stif-adressed Envelope <br /> MAKE CHLCYiS PAVAIt)L'C to)viol) <br /> App"-at agraear to all aeceatafy ioui»•'tiona incident to icsuxace of a PERMIT TO OPERATE. Applitsat agrees that this project(camp)shall be Operated <br /> Dad maintained in aecurdanet pith the applkabk provisions of the 0,1PL.OVIDE ROU91NC ACT,Chkpter 1,Part 1,Division 13 of the Cgl{fomin Hookk <br /> and Ser(?Code artd Chaptcr 1,Sabebaptcr 3,Title 25,C0jcrrreta Cody of ftutartonr. <br /> Applicant Some (\��Q R )1 .\'" '��� (� Title ❑Parit>erahip <br /> ;Pip"a PRINT or YY1'!=�`�-- ��-•+• \ � / - U cogArstion <br /> Address ����i2� �U -����5 s' i t��' ( `�l ✓ zi? Phone x a91__ C' ---; ty.�3 c-,�J <br /> Applkant Signature "� ' c" Date of Application - <br /> AmountFaid Dale ofF"Wv PuymetAType Chea aatpt0 RoealvodOy AccountD <br /> 0-7 , o D <br /> Peeltay 10 P.ogram Record ID PIE AssiWied to PWS Ila <br /> Oc)0 3 3 PI 536 -—N►Cie_ 0 <br /> PAYMENT <br /> RECEIVED Application Printed:eranuf0 <br /> AUG 2 5 20% <br /> SAN JOAQUtN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />