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c- Joaquin County-Environmental Health Department <br /> 304 E Webt enue-Third Floor-Stockton CA 95202-Phi 209-468-3420 <br /> APPLICATION Apt., <br /> ENVIRONMENTAL HEALTH I <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) 12 Annual Permit for Calendar Year 2 0 0 3 <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 any Corrections or Changes in Facility/Operator Information directly on this ICamp 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: kiYesNLJ <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 /> Housing Accommodations to be Utilized this Year: Occu anc Dates: <br /> Buildings Employees from_/_! 3to12/ 31�&op <br /> Dormitories from_/_%_to_/_/_Crop _ <br /> SF Dwellings <br /> Apartments Total Number of Days to be used this Calendar Year-3 6 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 1��_ @ $12.00 each=$ 1 475 00 <br /> ❑ Orchard Camp Permit Fee: $95.00=$ <br /> nn Transfer of Ownership: $20.00=$ <br /> El Late <br /> Amendment Fee: $20.00+ Number of Additional Employees @ $12.00 each=$_ <br /> Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be uQmitted with Application TOT PAf1N- <br /> 1475.00 <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Address o <br /> MAKE CHECKS PAYABLE TO: PHS-EHD <br /> a A, 2111103 <br /> SAN JOAQUIN COUNTY <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrR 1kat Ltj0s;pr94e%[(tamp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,ChapteV11;-P3irt 1,DrAiidA!13 U the California Health <br /> and Safety Code and Cha ter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Tor Zuckerman Heritage, Inc. <br /> Applicant Name by Trey Ste rt Title Operations Director El Partnership <br /> (Please PRINT or TYPE) RI Corporation <br /> Address PO Box 7 Stoc ton, CA 95201 Phone 209 469 7979 <br /> Applicant Signature /l- KM Date of Application 1 /2 9/0 3 <br /> Amount Paid Rate of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0002525 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> 0002963 0270316 2755 1084-RAMIREZ 0002954 <br /> Report#:7066.rpt Application Printed:11/20/2002 <br />