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San Ioafttli_n County-Environmental Health Department <br /> 304 E Weber/ to-Third Floor-Stockton CA 95202-Phone 9-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH JJ TP <br /> PERMIT TO OPERATEEMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year 2003 <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 arty 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 No <br /> Owner Address: PO BOX 487,STOCKTON CA 95201 Owner Phone#:(209)464-8355 <br /> Community Facilities Provided by Camp: Community Kitchen: 50YesN <br /> Men: Number of Toilets j— Number of Showers i 7 Number of Lavatories _19_ <br /> Women: Number of Toilets Number of Showers Number of Lavatories _ <br /> Housing Accommodations to be Utilized this Year: Occupanc Dates: <br /> Building Employees from_/_/ 3to12/_j1_�&op <br /> Dormitories from_/_/_to_/_/_Crop <br /> SF Dwellings <br /> Apartments Total Number of Days to be used this Calendar Ye2r_36 5 <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 /> �1 Permanent Camp Annual Permit Fee: $35.00+ Number of Employees IN @ $12.00 each-S 1475 00 <br /> 'jE' ❑ Orchard Camp Permit Fee: $95.00=S <br /> Transfer of Ownership: $20.00-S <br /> Permit Amendment Fee: $20.00+ Number of AQional Employees @ $12.00 each=S_ <br /> ❑ <br /> Late Application Fee: $70.00+ Number ofEmployees @$24.00 each=S <br /> Fee must be Lu matted with Application PA' ENT <br /> TOT 1475.00 <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addres'ski lope­ <br /> MAKE CHECKS PAYABLE TO: PHS-EHD <br /> .JAN 3 t 'Z403 <br /> SAN JOAOIJiN COUNT'( <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrrilt"01I AiS!proljWL(tamp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,ChaptiNd KTa1Nf 7;10PvSfidirl I'3'Kf ffie California Health <br /> and Safety Code and Cha er 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Vor Zuckerman Heritage, Inc. <br /> Applicant Name by Trey Ste' rt Title Operations Director [I Partnership <br /> (Please PRINT or TYPE) Corporation <br /> Address PO Box 1A7(Sto-k1ton, CA 95201 Phone 209 469 7979 <br /> Applicant Signature /l. D ate of Application 1 /29/03 <br /> Amount Paid 15ate of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0002525 <br /> Facility ID Program Record ID P/E Assigned to PAIS ID <br /> 0002963 0270316 2755 1084-RAMIREZ 0002954 <br /> Report#:7066.rpt 3 J' -2(.b v Application Printed:1 112 0/20 0 2 <br />