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rug. 17 L',' It1 Q./Lnlrl ?'•: �Udqu i , 14vu11ty I%V. U771 i <br /> • -man Joaquin County-Environmental Hexlth DcptrtmL <br /> 600 E.Main Street-Stockton CA 95202-Phone: 204-468.3420 <br /> APPLICATION <br /> EINViR.ONMENT,QI.REALTII <br /> PERMIT TO OPERATE <br /> gJPl-OYEJE HOUSING OR L APOR CAMP <br /> ['New Camp ❑Conditional rtrwlt ❑ Muhiple Years(Fxrnx*tni lionaine Campo uoly) ❑Anrstta:Pen sit Ca Caleodar I car _ <br /> ❑Atauadrdrsrmir. *Ch"teuf0ptratur •Change OfOwaar <br /> -Change of Oparatoe Addroaa 'Change of Owner Addrtw <br /> -AALLE"al 8apleya <br /> ermit LD p <br /> Fleaye Nore a7ry Corrections or Clwrcges in Faci??p+'type-error lr/rrrer:rlon Jrrectly on this Camp ID : <br /> Site Name: Location: I ( Y13 N. bA VI 5 <br /> Operator: -� \ ` �•• <br /> MaWstQ Address _ s ,1J'. �,�� lyuclltty Phone N; �1 ?J,G <br /> Legal Owner: '> ,� -- ` _ New Owsar! ❑Yes ❑ No <br /> Ovv�rA.ddres+ r atrPhone O: <br /> Coroanunity Facilities Provided by Carrot Cotrunuriry Kiuher.? ❑ Yee N_ <br /> Men: Number of Toilers 'Nurnber of Showers _ Nambcr of Laratorics <br /> Women: rumba of Toilet-, Number of Showers Number of Lavatories <br /> Hcuaite Accommodatiane to be ti]' ed t is!'car: 0CeeDaltti Date <br /> I ttl.dia¢s lot'efs <br /> UGrmirGrieS �'Grt1 <br /> -1—!—to—/—I— Crop <br /> SF Ih,xtlwys —~ from —/—f to_l l Crop <br /> Apatmcna -- <br /> Owner Owned NIH/P:'4 r Total Number of Days to be used this Calandw Year: <br /> Owner Owned RR Care — Total!:Jays Owupie9 by 25 or more EmploWs: <br /> Ivil t/LCV Spaces Note <br /> Y�I L..� Comps occupied-by rxor marrFxwtoyeerN"#or neore-da7strra-MT- -- <br /> ALA Require a L"LIC WATLR SYSTEM Patau <br /> ❑Inactive <br /> Im ortatitt In order Io protect your land vse eAtvs,if eto p will iwt be utc`d&;yera t•.tn is intended for u2e in the Jotllre,.CbecE this Box ayd-alum this application. <br /> o�■a .t <br /> Feesebedele <br /> IM Petman^nt Camp Annual Penn:(I e, 135.00+ Number of Employeos _ _ (�SLIM each-$ <br /> [] Orchard Carry Permit Fee $95.DO-S— __!_ <br /> ❑ IhWfcr of Quncrship $20.DO-S <br /> [] permw,en_Aateaament r'ee $20.00+ NLTaberof Additional Employeas Cry$L2.00 each-S <br /> [� trite Application Fee $70.00+ Number of 2snployetta $24.00 etch-S <br /> Fee must be submitted with Application <br /> TOTAL PEE DLit,S Q <br /> Rtmit'I'MAL FEE as CAL(::tIL.ATED AEOVE In the ENCLOSED Self-adressed Envelope. <br /> AUKS CHLCICS PAVAE'Llf to EUD <br /> Appl"at agree+to all naceerary irtspecfioa.s iecidont to urussee of a PERAUT TO OFERAVE. Applitaat tigress that this project(euro)shall be operand <br /> and maintained is acurrdaucr pith the npplicabie provisions of the V:' PLOV9E HOUSNC ACT,Chapter 1,Part 1,Division 13 of the Cal(farnin Health <br /> trod SiLrory Code and Chapter 1,SubchaFtcr 3,Title 25,Callforit?a Corte eRcgularlons. <br /> \\ l 1 ' <br /> Title ❑F'ettt—hip <br /> Applicant Name <br /> :P4ale MN or 7YPC,`l ❑Carparation <br /> Addres4 <br /> ApplieRnt Signature �, , ,yoQ — c+ — Date of Application g -- ) 1 <br /> Arno mt Pald Dsle Vrpa'yrnarif Payment Type Cheri acaipt 0 Rscelwd by Account 0 <br /> -_—--g-o-- �L- <br /> racliky <br /> — / -oc , c� �( 533 rL- <br /> ID P.ogram Record ID P/E Amigood to PWS ID <br /> PAYMENT <br /> Reoort8:7°BTrd RECEN ED Applcelion Printed:tY42010 <br /> AUG 2 5 2010 <br /> SAN JOAQUrN GUUNM <br /> ENVIRONMENTAL <br /> uc n,TH OEPARTMENT <br />