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PAY, `IV T <br /> Joaquin County-Environmental Health Depar. ,t RECEIVED <br /> 600 E. Main Street-Stockton CA 95202-Phone: 209-468-3420 <br /> JAN 2 <br /> UN JOAQtjrt4 <br /> APPLICATION HhmR N Fcou <br /> VTk <br /> ENVIRONMENTAL HEALTH oEPARTME"r <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 20 <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#: 39000316 <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 /> Owner Address: PO BOX 487, STOCKTON CA 95201 Owner Phone#: i <br /> Communitv Facilities Provided by Camp: Community Kitchen? 9 Yes ❑ No <br /> Men: Number of Toilets _ Number of Showers I� Number of Lavatories t <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Emnlovees <br /> Dormitories from A_/ ( /-1-5—to M/ 1/ Cropl POT Gp• <br /> SF Dwellings from --t—/ to&/ / Crop 11 t t 1 <br /> Apartments <br /> Owner Owned MH/Rell= 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 /> ?i Require a PUBLIC WATER SYSTEM Permit <br /> El Inactive ��TT <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 /> 19 Permanent Camp Annual Permit Fet $35.00+ Number of Employees @$12.00 each=$ v <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 Employees cr,$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees C$24.00 each=$ <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 ��•Z�� '1,�1 (`SC) Title Q?� 1- O IAS O ❑ Partnership <br /> (Please PRINT or TYPE) N Corporation:TVGri Phon�UC L�GraGAddress a O <br /> Applicant Signature Date of Application L <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 323.6D 1 _ 13 ✓ )r�2-7 0002525 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002963 PR0270316 2765 a <br /> }©20 9-SOOD WA0461342 <br /> Report#:26F}.rot pp <br /> ®61�Ca A lication Printed:11/1/2012 <br /> �, <br />