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s Joaquin County-Environmental health Depar it <br /> 304 E Webt, enue-Third Floor-Stockton CA 95202-Pho. 209-468-3420 <br /> PA\Irl--• •. - <br /> APPLICATION RECEIVED <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE FF D 6 20�4 <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> $pjO�AOU�INCOU <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent(lousing Camps only) Annual Permtf fN J � e — <br /> ❑Amended Permit: *Change of Operator *Change of Owner HEALTH DEPARTMENT <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 0001954 <br /> Please Note any Corrections or Changes in Facility/Operator htformation 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 <br /> Owner Address: PO BOX 487,STOCKTON CA 95201 Owner Phone#:(209)464-8355 <br /> Community Facilities Provided by Camp: Community Kitchen: LXYesNL1 <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 /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildinms Employees from o_U__31_L_@rIbp <br /> Dormitories from_/_/_to_/_/_Crop <br /> SF Dwellings <br /> Apartments total Number of Days to be used this Calendar Year <br /> Owner Owned MH/RV Total Days Occupied by 25 or more Employees_ 275 <br /> Owner Owned RR Cars Note: <br /> MH/RV Spaces Cramps occupied by 25 or more employees for 60 or more days in a year <br /> TOTALS 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 retum this application. <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fee: $35.00+ Number of Employees-�-�p� e $12.00 each=$ 1147 5 0 0 <br /> ❑ Orchard Camp erl'`mit Fee: $95.00=$ <br /> nn Transfer of Ownership: $20.00=$ <br /> ❑ Permit Amendment Fee: $20.00+ Number of AQtITtional Employees _ a $12.00 each=$_ <br /> Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be iu mitted with Application <br /> TOTAL FEE DUE: $ 1475.00 <br /> Remit TOTAL.FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope <br /> MAKE CHECKS PAYABLE TO: PHS-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 El Partnership <br /> �. �o�i C+nirih7i-i> <br /> (Please PRINT or TYPE) lay R)Corporation <br /> Address PO Box 7 tockton CA 95201 Phone 209 469 7979 <br /> Applicant Signature Date of Application 1 /27/04 <br /> Amount Paid ate of Payment Payment Type ec eceipt# Received By Account ID <br /> /( �7� �/� �� ✓ 1;71 �D 0002525 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> 0002963 0270316 2755 1084-RAMIREZ 0002954 <br /> Report#:7066.rpt w 1-7 l/ Application Printed:11/19/2003 <br />