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c `oaquin County-Environmental Health Departr---t gpY mew <br /> p <br /> 6001 -ain Street-Stockton CA 95202-Phone: 209-• A20 RECE,V E <br /> APPLICATION <br /> SAN JOAOUIN CoUNrr <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP WEALTH DEPARTMENT <br /> New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year 2(109 , <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 0002954 <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 ',cv�Owner? ❑Yes q No <br /> Owner Address: PO BOX 487,STOCKTON CA 95201 Owner 1'honc 4: <br /> Community Facilities Provided by Camp: Community Kitchen'? $] Yes ❑ 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 EmMovees <br /> Dormitories 2 15 from 1/1/ 09 to I 31/ 09 CropTurf, Potato, Asp. <br /> SF Dwellings ,r j from I /1/-9-to 12 '31 /O 9 _ Crop <br /> Apartments <br /> Owner Owned MH/RV g Total Number of Days to be used this Calendar Year: 3 6 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 50 <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> 3 0 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 /> ER Permanent Camp Annual Permit Fet $35.00+ Number of Employees if) _ @$12.00 each=$ R 6 0 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 @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ 9 5 0 0 <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 C ter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name ror: Zuckerman-Heritage, Inc. Title O erations Director ❑Partnership <br /> g.,• T.1 c�iRhar-+ p <br /> (Please PRINT or TYPE) 7T �P �CoipOiatiO <br /> Address PO Box 487 StoC n, CA 95201 Phone 209 469 7979 <br /> Applicant Signature ( Date of Application 1 1 /1 1 /08 <br /> Amount Paid Date of Payment Payment Type Check5tiliceipt# Received By Account ID <br /> 1/33 �f 0002525 <br /> Facility ID Program Record ID P/E 7 Assigned to !•� — PWS ID <br /> FA0002963 PR0270316 2755 208 SOOD WA0461342 <br /> Reoort#.7066.rot Date I1/zo/pg_ j Application Printed:10/30/2008 <br />