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Joaquin County-Environmental Health Depo 'nt PAYMENT 304 E Web, _venue-Third Floor-Stockton CA 95202-Ph, 209-468-3420 RECEIVED (J APPLICATION ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) [ Annual Permit for Calendar Year 2005 ❑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 ® No:::] Owner Address: PO BOX 487,STOCKTON CA 95201 Owner Phone#:(209)464-8355 Community Facilities Provided by Camp: Community Kitchen? [3d Yes ❑ No Men: Number of Toilets 8 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 /05 to 12/ 31 05 Crop 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 Permanent Camp Annual Permit Fe $35.00+ Number of Employees 85 @$12.00 each=$ 1020.00 ❑ Orchard Camp Permit Fee $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Pet maueut Amendmcni Fee $20.00+ NUITIner of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 1055.00 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 ror: Zuckerman-Heritage, Inc. Title Operations Director ❑Partnership (Please PRINT or TYPE) ®Corporation Address PO Box K87 Stockton, CA 95201 Phone 209 469 7979 Applicant Signature t Date of Application 1 /2 0/0 5 Amount Paid Date Y PAyfnent Payment Type Check/Receipt# Received By Account ID 0002525 l DSS•oo 1��65 `� _7S 76) Facility ID Program Record ID P/E Assigned to PWS ID FA0002963 PR0270316 2755 1084-RAMIREZ WA0461342 Reoort#:7066.rot Application Printed:10/29/2004