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- I`,V�IEk <br /> Joaquin County-Environmental Health Depar t i r=I VF I <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN O COONIY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> ENTAL <br /> HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year 2006_ <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 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 0 No <br /> Owner Address: PO BOX 487, STOCKTON CA 95201 Owner Phone#:(209)464-8355 <br /> Community Facilities Provided by Camp: Community Kitchen? 2 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 Employees <br /> Dormitories from _j_/ 1 6 to12/ '41/ 06 Crop Turf, Potatoes, Asr <br /> SF Dwellings 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: 55 <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 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 /> F0 Permanent Camp Annual Permit Fe $35.00+ Number of Employees 5()_ @$12.00 each=$ 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 Apphcation Fee $70.00+ Number of Empioyees (a,$24.UU each=:b <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ 636.00 <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 Name For: Zuckerman-Heritage, Inc. Title Operations Director ❑Partnership <br /> (Please PRINT or TYPE) 5a Corporation <br /> Address PO Box 4 7 Stoc ton CA 95201 Phone 209 469 7979 <br /> Applicant Signature Date of Application 1 /30/06 <br /> Amount Paid Date of Pay ent Payment Type Check/R ceipt# R-ec%e�ived By Account ID <br /> ( 3 �i. l7 I /U (o ✓ )-3171 F /�I'� 0002525 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002963 PR0270316 2755 1084-RAMIREZ WA0461342 <br /> Report#:7066.rDt l d�I { t7 O� S O 0 Application Printed:11/16/2005 <br />