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Joaquin Codikiy-ErNironmental Health Depa. it PAYMENT <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 RECEIVED <br /> APPLICATION <br /> f s 0 2 2007 <br /> ENVIRONMENTAL HEALTH SA .^AQUIN COUNTY <br /> PERMIT TO OPERATE FJgVIRGNMENTAL i <br /> EMPLOYEE HOUSING OR LABOR CAMP 14EAtTtiDEPARTMEW <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar Year 2007 <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 thi. 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 Q No <br /> Owner Address: PO BOX 487,STOCKTON CA 95201 Owner Phone#:(209)464-8355 <br /> Community Facilities Provided by Camp: Community Kitchen? [K.Yes ❑ No <br /> Men: Number of Toilets 8 Number of Showers 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 2 25 from 1/ 1 / 07 to 12/ 31/ 07 Crop Turf, POtatoe, Asp. <br /> SF Dwellings 4 25 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: 1; <br /> ME/RV Spaces <br /> 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 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 SQ_ @$12.00 each=$ 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$ 635.00 <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 /> A IicantName For: Zuckerman-Heritage, Inc. Title ❑Partnership <br /> PP B Operations Director n <br /> (Please PRINT or TYPE) �!Corporation <br /> Address on CA 95201 Phone 209 469 7979 <br /> Applicant Signature Date of Application 1 /2 9/0 7 <br /> Amount Paid Date of Payment Payment Type Checkk/ 6 <br /> /Reeetpt# Received By Account ID <br /> 2) S• dD a -a 0 ' l l\ � �' s (�— 0002525 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002963 PR0270316 2755 1084-RAMIREZ WA0461342 <br /> Report#:7066.rpt awf 1 �J ' Application Printed:10/23/2006 <br />