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San Joaquin County-Public Health Services A Environmental Health Division 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 KIf' l.: a APPLICATION ENVIRONMENTAL HEALTHPERMIT TO OPEATE EMPLOYEE HOUSING OR LABOR CAMP DEC', 8 2001 ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) [f;W W,9iWAA&WA-hdaf--1)rTH02 ❑Amended Permit: *Change of Operator *Change of Owner PERMIT/SERVICES *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: 0002954 ��] Please Note any Corrections or Changes in Facility/Operator Information directly opt this 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 Communitv Facilities Provided by Camp: Community Kitchen: KI'yesNLI Men: Number of Toilets 8 _ Number of Showers 17 Number of Lavatories 1 9 Women: Number of Toilets Number of Showers Number of lavatories _ Housine Accommodations to be Utilized this Year: Occu anc Dates: Buildings Employees from_/_ U Zto 1213I/ U Xrop Dormitories from_/_/_to_/_/_Crop SF Dwellings Apartments Total Number of Days to be used this Calendar Year_365 Owner Owned MH/RV Total Days Occupied by 25 or more Employees_-2 7 5 Owner Owned RR Cars Note: MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year TOTALS 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 Fee: $35.00+ Number of Employees 120 @ $12.00 each=$_ 1475.00_ ❑ Orchard Camp Permit Fee: $95.00=$ ((''�� Transfer of Ownership: $20.00=$ Permit Amendment Fee: $20.00+ Number of Achttlional Employees @ $12.00 each=$_ ❑ Late Application Fee: $70.00+ Number of Employees n $24.00 each=$ Fee must be uQmitted with Application TOTAL FEE DUE: $ 1475.00 Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope MAKE CHECKS PAYABLE TO: PHS-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 Safery Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name - Trp)t Steinhart Title Operations Director ❑Partnership (Please PRINT or TYPE) n Corporation Address 1 Phone 209 469-7979 Applicant Signature f— Date of Application 12-14-01 Amount Paid Date of Payme t Payment Type Check/Receipt# Received By Account ID 0002525 Facility ID Program Record ID PIE Assigned to PWS ID 0002963 0270316 2755 1084-RAMIREZ 0002954 Report#:7066.rpt � Application Itcalion Printed:11/19l01