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PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> JAN 1 6 2f23 2(29 <br /> APPLICATION SAIN JO,AQUII Ol COUNTY <br /> ENVIRONMENTAL HEALTH ENVIRONMENTAL <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP ! <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year 2-0-`4 <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0002954 <br /> *Additional Employees <br /> State ID#: 39-0316-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form EH ID#: 39000316 <br /> Site Name: ZUCKERMAN, ROSCOE 39-316 Location: MCDONALD ISLAND,STOCKTON <br /> Operator: ZUCKERMAN-HERITAGE INC <br /> Mailing Address: PO BOX 487,STOCKTON CA 95201 Facility Phone#:(209)464-8355 <br /> Legal Owner: ZUCKERMAN-HERITAGE INC \CN�O„ner° ❑Yes ❑ No <br /> Owner Address: PO BOX 487,STOCKTON CA 95201 Owner Phone#:(209)469-7979Ext: <br /> Community Facilities Provided by Camp: Community Kitchen? 10 Yes ❑ No <br /> Nlen: Number of Toilets 19 Number of Showers [ "'1 Number of Lavatories (q <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housin¢Accommodations to be Utilized this Year: Occunancv Dates: <br /> Buildines Emolovees <br /> Dormitories j- Pj from Crop -7or(- I R+c1A,0_ <br /> SF Dwellings L_ Cl from (/Ok/ 2t to_[2n/3) / 2!9 Crop -TU l`� {O <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 /> MH/RV Spaces to <br /> TOTALSCamps occupied by 25 or more Employees for 60 or more days in a year <br /> 2� Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> m rtant: 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 <br /> ® Permanent Camp Annual Permit Fee $50.00+ Number of Employees 2L @$17.00 each=$ H01,00 <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. <br /> Applicant Name —T`ei rj�L;yl Title Partnership <br /> ❑Partnership <br /> (Please PRINT or TYPE) [rorporation <br /> Address c) 6n)( QT? y Stdek�ar\ , Ca 452.Ok PhonI20q 1 4(cG- 7Q7q <br /> Applicant Signature Date of Application 2 <br /> Amount Paid Date of Payment Payment Type Check/ e c e i p t# Received By Account ID <br /> 1 O I1 n k' I �� 0002525 <br /> Facility ID Program Record ID P/E I-t' Assigned to PWS ID <br /> FA0002963 PR0270316 2765 9834-SUSZYCKI WA0461342 <br /> Report#:7066 Application Printed:11/1/2023 <br />