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• 3oaquin County-Public llcalth Service- <br /> Environmental llcalth Division <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202- Phone: 209-468-34211 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Carnes only) ❑Annual Permit for Calendar Year 2001 <br /> ❑Amended Permit: *Change or Operator *Change of Owner <br /> *Change or Operator Addres; 'Change of Owner Address <br /> 'Additional Employees Permit ID#: 0002954 <br /> Pleme Note mtv Corrections or Changes in Facility/Operator Information directly <br /> Camp ID#: 39000316 <br /> Site Name: <br /> ZUCKERMAN,ROSCOE 39-316 Location: MCDONALD ISLAND,STOCKTON <br /> Operator: ZUCKERMAN-HERITAGE INC <br /> Mailing Address: PO BOX 487,STOCKTON CA 95201 <br /> Facility Phone#: (209)464-8355 <br /> New psrner? ❑Yes No <br /> LOwner <br /> wner: ZUCKERMAN-HERITAGE INC - <br /> 209 464-8355 <br /> ddress: PO BOX 487,STOCKTON CA 95201 <br /> Owner Phone#: ( ) <br /> Community Kitchen: No <br /> Community Facilities Provided by Camp; y Number of Lavatories 19 <br /> Number of Showers 1 7 <br /> Men: Number of"toilets 8 Number of Lavatories <br /> Women: Number of Toilets Number of Showers <br /> Occupancy Dates: <br /> Housin Accommodations to be Utilized this Year: from OI O 1 O lto 121311O1 Crop <br /> _ j__t�YNjL.�J.I <br /> Buildings Employees --- — �E�FI <br /> from I l ta_- I Crop <br /> Dormitories VE-I-,i <br /> SF Dwellings Total Number of Day%to he used this Calendw Year 365 <br /> Apartments <br /> rr.. <br /> y� �� 4 4 <br /> Owner Owned MHlRV <br /> TotalDaya occupied by25or more F,mpb}res 275 <br /> Note: <br /> Owner Owned RR Cars <br /> MH/RV Spaces Camps occupied by 25 or more employees forit <br /> /?!�Jlnii��jeiar <br /> require a Public Water Syste�iti 6'i' 11 Ig7,il I Ii Ai ill l;i„i ilnfd <br /> To'rnl s <br /> ❑ lnactivc —J <br /> ill not be used this but is intended for use in the future,Check this Box and return this application. <br /> Important: In order to protcetyour land use status,if camp w <br /> Fee S_cliedulc .60 !415, <br /> 12 0 @ $1200 each=S <br /> ❑Permanent Camp Annual Permit Fee: $35.00+ ❑Number of Employees__ <br /> Orchard Camp Permit Fee: S95.00=S <br /> ❑ Transfer of Ownership: $20.00=$ <br /> @ $12.00 each=S <br /> ❑ PertttitAmcntlntent Fee: $20.00 � Number of Additional Employees____ @ $24.00 each=S <br /> ❑ Late Application Fee: $70.00+ Number of Employee <br /> Fee must be submitted vAth Applicatio— <br /> nTOTAL FEE DUE: S 1 .00 1 y75, <br /> RemitTOTAL FF.E as CALCULATED ABOVE in the ENCLOSED Self-Addressed nvelope �9 70 <br /> MAKE.CHECKS PAYABLE TO: PHS-EHD <br /> his <br /> ect <br /> Applicant agrees to all necessary inspections incident toai)'uarov i ne of a Pof the EMPLOYERM IT TO EE H OUSING Applicant <br /> CT, Chapter that <br /> lt Part 11 Divi imr13 of shall <br /> th <br /> operated and maintained in accordance with the apphc 1 California Code ojKegulatfotts <br /> California llcalth and Snfe4y Code and Chapter 1,Subchapter 3,Title 25, Title Operations Director El Partnership <br /> Applicant Name Trey SteinhartCorporation <br /> (Please PRINT or TYPE) Phone 209-469-7979 <br /> Zuckerman-Heritage, Inc. P.O.- Box 487, Stkn. , CA 95201 <br /> Address / 1-22-01 <br /> Date of Application <br /> Applicant Signature � � �. . �' , l <br /> Check/Receipt# Received By Account ID <br /> Date of Payment Payment Type 0002525 <br /> Amount Paid y <br /> I�?s. - a-11'-1-Iv I PWSID <br /> PIE Assigned to <br /> Facility ID Program Record ID 1084-GALAPIA 0002954 <br /> 0002963 0270316 2755 <br /> Application Printed:11/7/00 <br /> Report#:7066.rp1 <br />