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PAYMENTSan Joaquin County-Environmental Health Department <br /> RECEIVE 8 E Hazelton Ave-Stockton CA 9$20i-Phone: 209468-3420 <br /> APPLICATION " J ,ln <br /> APR 14 2026 ENVIRONMENTAL <br /> p RMITTOOPERATETH ��IV�RONly��N w <br /> SAN JOAQUIN COUNTY EMPLOYEE HOUSING OR LABOR CAMP P �glFzc'Q.�H�4CT/l <br /> �/����r V,C'�S <br /> ❑New Camp H�EN�.7���J�161MTt111� ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit for Calendar fear 2026 <br /> ❑ Amended Permft:�M.R TMENT "Change of Owner <br /> "Change of Operator address "Change of Owner Address <br /> "Additional Employees <br /> State ID#:39-0316-EH <br /> Please!Vote any Corrections or Changes in Facility/Operator Information directly on dtis form. <br /> Site Name: ZUCKERMAN,ROSCOE 39-316 Location: 0 MCDONALD ISLAND STOCKTON <br /> Operator: ZUCKERMAN,ROSCOE 39-316 Entail: <br /> Mailing Address: PO BOX 487,STOCKTON CA 95201 Facility Phone#: (209)469-7979 <br /> Legal Owner: ZUCKERMAN-HERITAGE INC New Owner? ❑ Yes ❑ No <br /> Owner Address: PO BOX 487,STOCKTON CA 95201 Owner Phone#: (209)469-7979 Entail. <br /> Community Facilities Provided by Camp: Community Kitchen? ® Yes ❑ No <br /> Men: NumberofToilets Number ofShowers f�- NutnberofLavatories A <br /> Women: NumberofToilets Number of Showers Number of Lavatories <br /> HousineAccommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees ( ` ,'� •tl, -241 C� fz (� j�`i (I , <br /> Dormitories _h from / / to Crop ��� i l f"�� <br /> SF Dwellings /1. from ( / ( / Z6 to IZ/ 3 / olk Crop �4 Ain'r,45 <br /> Apartments —!— <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3 65 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MHJ RV Spaces <br /> 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,Check this Box and return Otis application. <br /> Fee Schedule <br /> ® Permanent Camp Annual Permit Fee $54.00+ Number of Employees 7If @$17.00 each=$ <br /> ❑ Transfer ofOwnership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number ofAdditional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $108.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUES �Z•w <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed 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 and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,Califorida Code ofRegulations. <br /> Applicant Name Trem Sta th-wt Title 0,'!drAtlOnS b-1>utoY' ❑Partnership <br /> (Please PRINTor TYPE) I Corporation <br /> Address S a Phone � � "to '3V 1 <br /> Applicant Signature Date of Application <br /> Amount Paid Date o ment Payment Type Check/Receipt# Received By <br /> LI T��.dZ5 31 f `i5 3 c� L'K, i- 33 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002963 PR0270316 765 astina Tltammavongsa <br /> Report#:7067.rpt <br />