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Pe4YAAE(11T San Joaquin('Dunt)-Environmental Health Department <br /> !� <br /> RECEIVE '8EHazelton Ave-Stockton CA 95205-Phone: 209-468-3420 <br /> APPLICATION V <br /> APR 14 2026 ENVIRONMENTAL HEALTH ENV1R �J <br /> PERMIT TO OPERATE p)r ONMENTq <br /> SAN JOAQUIN COUNTY EMPLOYEE HOUSING OR LABOR CAMP -RMITjg;R�H�CTH <br /> ❑New Camp HErzN�'y�/��p�/eQ1WM 1#Tik ❑ Multiple Years(Permanent(lousing Camps only) ® Annual Permit for Calendar Year 2026 /CSS <br /> ❑ Amended P!rniu` *("ISdn!' WAW ATMENT "Change or Owner <br /> *('hank of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> State ID#:39-0316-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on Phis form. <br /> Site Name: ZUCKERMAN,ROSCOE 39-316 Location: 0 MCDONALD ISLAND STOCKTON <br /> Operator: ZUCKERMAN,ROSCOE 39-316 Email: <br /> Mailing Address: PO BOX 487,STOCKTON CA 95201 Facility Phone#: (209)169-7979 <br /> Legal Owner: ZUCKERMAN-HERITAGE INC New Owner? ❑ Yes ❑ No <br /> Owner Address: PO BOX 487,STOCKTON CA 95201 Owner Phone#: (209)369-7979 Email: <br /> Community Facilities Provided by Camp: Community Kitchen? ® Yes ❑ No <br /> Men: NumberofToilets $ Number of Showers �� Number of Lavatories /_1 <br /> Women: Number ofToilets Number of Showers Number of Lavatories <br /> IEousine Accommodations to be Utilized this Year: Occupancy Dales: <br /> Buildines Employees tL fz�Cz� <br /> Dormitories �_ ( from / ' / to / / Crop 2- i lay I_ <br /> SF Dwellings from I / ( / Zb to IL/ 31/ Al Crop .5014 tZ+z i /TWN�t1tTS <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: -366 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS ® Camps occupied by 25 or more Employees for60 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,Clack this Box and return this application. <br /> Fee Schedule <br /> ® Permanent Camp Annual Permit Fee $54.00+ Number of Employees 7 C $17.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees 11$17.00 each=$ <br /> ❑ bate Application Fee $108.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application 1 2 D <br /> TOTAL FEE DUE S T� <br /> Remit TOT.k1.FEE:asCALCULATED ABOVE in the ENCLOSED Self-addressed Envelope <br /> \.LAKE 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 and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name Tley1 StteiAkAft Titley,fa,t;OnS btyto-r ❑Partnership <br /> (Please PRINTor TYPE) ®Corporation <br /> Address PuOA Uap k Phone (am) <br /> Applicant Signature Date of Application <br /> Amount Paid Date o ayment Payment Type Check/Receipt# Received By <br /> Ll •D-D 3hf -6 3l� CK, tt 33 <br /> Facility ID Program Record ID PIE Assigned to PVJS ID <br /> F.A0002963 PR0270316 2765 Sastina Thantmayongsa <br /> Report#:7067.rpt <br />