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Joaquin County-Environmental Health Depa, nt r[1 <br /> 304 E Webw venue-Third Floor-Stockton CA 95202-Pht. 209-468-3420 V 1 <br /> -- - <br /> APPLICATION RECEIVED <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE FEB 6 2��4 <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit f <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#: 0002914 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this JCamp 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 6a No <br /> Owner Address: PO BOX 487,STOCKTON CA 95201 Owner Phone#a(209)464-8355 <br /> Community Facilities Provided by Camp: Community Kitchen: [MYesNILJ <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 /> Buildings Emplovees from L/_L/Q4o 12_3(L 0h)p <br /> Dormitories from_/_/_to_/_/_Crop <br /> SF Dwellings _365 <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 Camps 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 return this application. <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fee: $35.00+ Number of Employees — @ $12.00 each=$ 147500 <br /> ❑ Orchard Camp eP rmit Fee: $95.00=$ <br /> nn Transfer of Ownership: $20.00=$ <br /> ❑ Permit Amendment Fee: $20.00+ Number of Alldl4ional Employees @ $12.00 each=$_ <br /> �t Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be u3 Omitted with Application 1475.00 <br /> TOTAL FEE DUE: $ <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 ❑Partnership <br /> o. ctei � <br /> (Please PRINT or TYPE) —lay�Tr�7—� R]Corporation <br /> Address PO Box 7 tockton CA 95201 Phone 209 469 7979 <br /> Applicant Signature Date of Application 1 /2 7/0 4 <br /> Amount Paid ate of Payment Payment Type ec eceipt# Received By Account ID <br /> /( I !6 �qG n 4 / 10:1 <br /> D 0002525 <br /> Facility ID Program Record ID V PIE Assigned to PWS ID <br /> 0002963 0270316 2755 1084-RAMIREZ 0002954 <br /> Reoort#:7066.rot Application Printed:11/19/2003 <br />