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)aquin County-Environmental Health Departt PAC VED <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209-468-A20 RE <br /> ,AN 3ON COONT'� <br /> 0 2012 <br /> APPLICATION SW JOIRONN Ebf kw, <br /> ENVIRONMENTAL HEALTH I{NTH DEPARTMENT <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP O I <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#: 0002954 <br /> *Additional Employees 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 U No <br /> Owner Address: PO BOX 487,STOCKTON CA 95201 011 ner Phone#: <br /> Community Facilities Provided by Camp: Community Kitchen? SQ Yes ❑ No <br /> Men: Number of Toilets Number of Showers Number of Lavatories I Cl <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Emnlovees �1 <br /> Dormitories �''� from 1 t / 2 to I I/�/ 1 Crop Tuy 'A <br /> SF Dwellings from i /I/I tz to M l Crop `k <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3 CQ <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> NM/RV Spaces Note <br /> TOTALS I ® 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: [n order to protect your land use status,if camp Nail)not be used this year but is intended for use in the future,Check this Box and return this application. <br /> Fee Schedule , L �2 �J- 6b <br /> Permanent Camp Annual Permit Fe( $35.00+ Number of Employees @$12.00 each=$ <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 @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees 2 t @$24.00 each=$ <br /> Fee must be submitted with Application 2 <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 /> (� <br /> Applicant Name ZM n— e7p kT 1 tt1e (x a—ra��Qn_& At'� Partnership <br /> (Please PRINT or TYPE) pti( C Te 1��k cA Corporation <br /> Address _ 1 J 1 Q Phone — C� <br /> Applicant Signature Date of Application <br /> Amount Paid Date of ayme t Payment Type Check/ ceipt# Received By Account ID <br /> 0002525 <br /> It T_ <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0Q�0+�029963 PR0270316 2765 20089-SOOD VVA0461342 <br /> Report#:70111 � � °ggG Application Printed:10/25/2�11 <br />