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S 'oaquin County-Environmental Health Departr <br /> 600 L ain Street-Stockton CA 95202-Phone: 209-4, 420 <br /> pAYMENT <br /> APPLICATION 3 i Z007 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE SAN JOAQUIN COUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTAL <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Ckj6 a6 QQ P'AWkNT <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 l 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 /> Leval Owner: _.- ZUCKERMAN-HERITAGE INC New Owner? ❑YesJa No <br /> Owner Address: PO BOX 487, STOCKTON CA 95201 Owner Phone#: <br /> Communitv Facilities Provided by Camp: Community Kitchen? ® Yes ❑ No <br /> Men: Number of Toilets $ Number of Showers 17 Number of Lavatories 1 q <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 2 25 from I/ I / (IS to 12 /31 /()R — Crop Pot-Was, A s p <br /> SF Dwellings 4 Z 5 from / / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: -365 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 50 <br /> MH/RV Spaces <br /> Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> © $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 /> 55 Permanent Camp Annual Permit Fet $35.00+ Number of Employees 5 f) @$12.00 each=$ 600 00 <br /> ❑ Orchard Camp Permit Fee $95.00=$ <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$ <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 Cha er 1,S cha ter 3,Title 2 California Code of Regulations. <br /> or. `L'ucKerman-Heritage, Inc. ❑Partnershi <br /> Applicant Name Title Operations Director p <br /> (PlsePRINT orTYPE) By- Trey C Steinhart P W Corporation <br /> Address PO Box kton, CA 95201 Phone 209 469 7979 <br /> Applicant Signature _ Date of Application 1 2/26/07 <br /> Amount Paid Date of Payment Payment Type C ec c t# Received By Account ID <br /> 0002525 <br /> I�,.5 od /2 Lc_:51 <br /> 2- <br /> Fa Ility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002963 PR0270316 2755 2089-SOOD WA0461342 <br /> Report#:7066,rot P if 1-73-�?— Application Printed:10/1812007 <br />