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I Joaquin County-Environmental Health Depart t PAYMENT RECEIV D 304 E Weber ,venue-Third Floor-Stockton CA 95202-Phone. 209-468-3420 APPLICATION ENVIRONMENTAL HEALTH SAN N COUNTY PERMIT TO OPERATE ENVVIRONIRONMEN TAL HEALTH DEPARTMENT EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year 2006 ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: 0002954 Please Note any Corrections or Changes in Facility/Operator Information directly on this I Camp ID#: 39000316 Site Name: ZUCKERMAN, ROSCOE 39-316 Location: MCDONALD ISLAND,STOCKTON Operator: ZUCKERMAN-HERITAGE INC Mailing Address: PO BOX 487,STOCKTON CA 95201 Facility Phone#:(209)464-8355 Legal Owner: ZUCKERMAN-HERITAGE INC New Owner' [-]Yes 0 No Owner Address: PO BOX 487,STOCKTON CA 952C1 Owner Phone#:(209)464-8355 Community Facilities Provided by Camp: Community Kitchen? 5d Yes ❑ No Men: Number of Toilets g Number of Showers 17 Number of Lavatories 19 Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories from _1 / 1 / (16 to12/ 31/ 06 Crop Turf, Pntatne Asp, SF Dwellings from _/_/ to_/_/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 365 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 55 MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive 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. Fee Schedule K] Permanent Camp Annual Permit Fe $35.00+ Number of Employees 50 @$12.00 each=$ 600-0 0 ❑ Orchard Camp Permit Fee $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late application Fee a70.UU+ ivumber of Employees (cii$24.UU each=�b Fee must be submitted with Application TOTAL FEE DUE$ 636.00 Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self=adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT, Chapter 1,Part 1,Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name For: Zuckerman-Heritage, Inc. Title Operations Director El Partnership (Please PRINT or TYPE) I Corporation Address PO Box 4 7 StoC ton CA 95201 Phone 209 469 7979 v Applicant Signature Date of Application 1 /30/06 Amount Paid Date of Pay ent Payment Type Check/R ceipt# Received ed By Account ID (a3 �._ l7 I D Ll I--- �-31 71 F 4,` 0002525 Facility ID Program Record ID PIE Assigned to PWS ID FA0002963 PR0270316 2755 1084-RAMIREZ WA0461342 Report#:7066.rot d�l �, t�0� Application Printed:11/16/2005