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PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 <br /> I A N I F 2024 <br /> APPLICATION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH ENVIRONMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year 2 02. <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0009595 <br /> *Additional Employees <br /> State ID#: 39-12046-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000326 <br /> Site Name: ZUCKERMAN-HERITAGE 39-326 Location: 10500 W HWY 12, LODI <br /> Operator: ZUCKERMAN-HERITAGE <br /> Mailing Address: PO BOX 487,STOCKTON CA 95201 Facility Phone#:(209)469-7979 <br /> Legal Owner: OLAGARAY BROTHERS New Owner? ❑Yes [,I No <br /> Owner Address: 2375 WARMSTRONG RD,LODI CA 95242 Owner Phone#:(209)339-8374 <br /> Community Facilities Provided by Camp: Community Kitchen? 19 Yes ❑ No <br /> Men: Number of Toilets Number of Showers (0 Number of Lavatories "1 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees <br /> Dormitories i 1 y from O 1/01/�_to 124 31' .2�j_ Crop --T J'C y � pot c 11 <br /> c <br /> SF Dwellings from _/ / to_/ / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> ME/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> © © 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 -K y <br /> 09 Permanent Camp Annual Permit Fee $50.00+ Number of Employees _ @$17.00 each=$ 2 3 'J <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$34.00 each=$ / <br /> Fee must be submitted with Application / <br /> TOTAL FEE DUE$ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to 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.Applicant Name St-ej n1(1(WC �Title hf)e 'Ion"- O i red" (— ❑Partnership <br /> (Please PRINT or TYPE) <br /> � j c, Corporation <br /> Address Yt 5P 7t kfvn �t5 aO,CA <br /> 2GI Phone ) L '79-7q <br /> Applicant Signature Date of Application _L213d 1Z"'- <br /> Amount Paid Date of Payment Payment Type Checkl eceipt# Received By Account ID <br /> 2ny).r 1 �— I n� l 0014892 <br /> ` acility ID Program R`e-c�o'rd ID (�P/E Assigned to PWS ID <br /> FA0007991 PRO508206 2765 0034-ARMED WA0515723 <br /> � t <br /> Report#:7066 Application Printed:11/1/2023 <br />