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S oaquin County-Environmental Health Departi PAYMENT <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 RECEIVED <br /> NOV 0 5 2013 <br /> APPLICATION SAN JOAQUIN COUNT) <br /> ENVIRONMENTAL HEALTH ENVIRONMENTAL <br /> HEALTH DEPAftT1AF"" <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 2-01 �f' <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 New Owner? ❑Yes No <br /> III <br /> Owner Address: PO BOX 487, STOCKTON CA 95201 Owner Phone#: <br /> Community Facilities Provided by Camp Community Kitchen? ;4 Yes ❑ No <br /> Men: Number of Toilets S Number of Showers Number of Lavatories. '-I <br /> Women: Number of Toilets Number of Showers Number o avator' s <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> ABuilEnt Dormitories from _L_/_L/_q_to 12 13 Crop 5oD, �1 oT4ToI t s5?Ay,�LA cS <br /> SF Dwellings from /�/ to�/ / 1{ Crop t 1 `t 1,4 <br /> Apartments // <br /> Owner Owned MH/ 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 <br /> 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 <br /> Permanent Camp Annual Permit Fe( $35.00+ Number of Employees 2 @$12.00 each=$ 2- <br /> Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Emnlovees @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application TOTAL FEE DUE$ J Z 3.Ott <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 and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name _T V*e_s4 6+p- n h�.r�- Title o, e radi(as ke��)r ❑ Partnership <br /> (Please PRINT or TYPE) N ZU�C P�I j l aim r Vr eG �COrporation <br /> Address 2 2 Phone�� -[�(aGt-�Ct 7Ci <br /> Applicant Signature YU, Date of.Application ( 6 13 <br /> Amount Paid 0.teof Payment /'Payment Type Check/Receipt# Received By Account ID <br /> O O t '7`7 Q 0 1 0002525 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0002963 PR0270316 2765 2089-SOOD WA0461342 <br /> Report#:7066 Application Printed:10/17/2013 <br />