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Joaquin County-Environmental Health Depar 9t <br /> 60C Jain Street-Stockton CA 95202-Phone: 209 -3420 <br /> PAYMENT <br /> kY1 VED <br /> APPLICATION ��\Y/L�1LJ1 <br /> ENVIRONMENTAL HEALTH FEB 2 4 2010 <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP SAN JOAQUIN COUNTY <br /> ENVIRONME�M[/A�LL <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for C1iII��aT4(@EPAi Fl1klhr <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 0001954 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this I Camp 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 2 No <br /> Owner Address: PO BOX 487,STOCKTON CA 95201 _ Owner Phone#: <br /> Community Facilities Provided by Camp: Community Kitchen? ® Yes FBI No <br /> Men: Number of Toilets 8 Number of Showers 17 Number of Lavatories 19 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories 17 1 15_ from 1 / 1 / 10 to12/ 31/ 10 Crop Turf, Potato, Asp. <br /> SF Dwellings _9, from 1 / 1 / 1 0 to 12/ 31/ 1 0 Crop rr <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 365 <br /> Owner Owned RR Cars Tctal Days Occupied by 25 or more Employees: <br /> MH/RV Spaces <br /> Note <br /> � Camps occupied by 25 or more Employees for 60 or more days in a year <br /> TOTALS © C4 <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 Fee $35.00+ Number of Employees 2 4 @$12.00 each=$ ?R R_00 <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 L$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ 323.00 <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 For: Zuckerman—Heritage, Inc. Title ❑Partnershi <br /> PP Operations Director p <br /> (Please PRINT or TYPE) by . Trey SteililldF t J�]Corporation <br /> Address PO B 87 Stockton CA 95201 Phone 209 469 7979 <br /> Applicant Signature Date of Application 1 2/2 8/09 <br /> Amount Paid ate of Paajyment Payment Type Check/Reeeipt# Received By Account ID <br /> 3 a 3 � — a l — 1 D LA q T( _ 0002525 <br /> Facility ID Program Record ID PIE Assigned to 1 PWS ID <br /> FA0002963 PR0270316 2765 1421 -RIVERA WA0461342 <br /> Report#:7066.rpt Application Printed:10/14/2009 <br />