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oaquin County-Environmental Health Depart. PA\,iIVI N i <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 <br /> FCCi_I EQ <br /> APPLICATION <br /> C 2 4 2olo <br /> ENVIRONMENTAL HEALTH SAN.;vAOUIN CUNN PERMIT TO OPERATE ENVIRONMEN <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH qg �- <br /> ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) V1 Annual Permit for Calendar Year (J A� <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 FacilitN Phone#:(209)464-8355 <br /> Legal Owner: ZUCKERMAN-HERITAGE INC Neis ONrner'I ❑Yes 14No <br /> Owner Address: PO BOX 487,STOCKTON CA 95201 Owner Phone 4:(209)469-7979 <br /> Community Facilities Provided by Camp: Community Kitchen? CA Yes ❑ No <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildin s Employees y /� <br /> Dormitories `•C from �/ /��to�/3 /�1 Crop A <br /> T. I 5i� <br /> SF Dwellings from �/�/�_to'�/�/_f_� Crop it <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: r) <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 /> ❑Inactive <br /> Important: In order to protect your land use status,if camp Nvill not be used this year but is intended for use in the future,Check this Box and return this application. <br /> Fee Schedule n �r Oc) <br /> Sa Permanent Camp Annual Permit Fe( $35.00+ Number of Employees @$12.00 each=$ L <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 @$24.00 each=$ <br /> Fee must be submitted with Application O <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 i Te ❑Partnership <br /> nPeRaT►cN � '���'roP, <br /> (Please PRINT or TYPE) �I: Corporati0 <br /> Address 1 Phone oq q— 9 <br /> Applicant Signature Date of Application K' O <br /> Amount Paid ate Payment Payment Type ChecklReceipt# Received By Account ID <br /> ^\ 0002525 <br /> Facility ID Du Program Record ID PIE Assigned to PWS ID <br /> FA0002963 PR0270316 2765 2089-SOOD WA046134 <br /> Report#:7066.rpt Application Printed:11/2/2010 <br />