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San.Joaquin County-Environmental Health Department <br /> 1868 E.Ha-relton Ave-Stockton CA 9520i-Phone: 209468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent HousingCamps 2026 <br /> onl•P y) ® Annual Permit for Calendar fear <br /> ❑ Amended Permit: "Change of Operator 'Change of Owner <br /> "Change of Operator Address 'Change of Owner Addre s <br /> "Additional Employees <br /> State II)#:39-0316-EH <br /> Please Note any Corrections or Changes in Facilil}'/01era[or Information directly on this jorm. <br /> Site Name: ZUCKERMAN,ROSCOE 39-316 Location: 0 MCDONALD ISLAND STOCKTON' <br /> Operator: ZUCKE:RMAN,ROSCOE 39-316 Email: <br /> Mailing Address: PO BOX 487,STOCKTON CA 95201 Facility Phone#: (209)469-7979 <br /> Legal Owner: •ZUC•KERMAN-HERITAGE INC New Owner? ❑ Yes ❑ No <br /> Owner Address: PO BOX 487,STOCKTON CA 95201 Owner Phone#: (209)469-7979 Email: <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: NumberofToilets Number of Showers Number of Lavatories <br /> Women: NumberofToilets Number of Showers Number of Lavatories <br /> I ousing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from / / to / / Crop <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 /> MH/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 /> El 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 <br /> ❑ Permanent Camp Annual Permit Fee $54.00+ Number of Employees C?$17.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees (a?$17.00 each=$ <br /> ❑ late Application Fee $108.00+ Number of Employees (a2$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL.FEE DUE:S <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed Envelope <br /> MAKE CHECKS PAN-ABLE 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 /> Safro�Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Title ❑Partnership <br /> .applicant Name <br /> ❑Corporation <br /> (please PRINTorTYPE) <br /> Address Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Recelpt# Received By <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> EA0002963 PR0270316 2765 Sastina Thanuum ougsa <br /> Report#:7067.tpt <br />