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Y v sI �r <br /> iAN JOAQUIN COUNTY • PUBLIC HEALTH . AVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E WEBER AVENUE • THIRD FLOOR • STOCKTON CA 95202 • Phone: 209/468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit 1&nnual Permit For Calendar Year <br /> ❑Amended Permit ❑Multiple Years(Permanent Housing Camps only) ate A roved <br /> • Change of Operator -Change of Owner ate Mailed: <br /> • Change of Operator Address • Change of Owner Address ermit# 00295 <br /> • Additional Employees lampID# 3900 16 <br /> Please Note any Corrections or LhnLes in Fac /O erator/Owner In orniatlon directlyon this foam <br /> Site Name: ZUCKERMAN,ROSCOE 39-316 _ _ Location_ MCDONALD ISLAND <br /> Operator: ZUCKERMAN-HERITAGE INC <br /> Mailing Address: PO BOX 487,STOCKTON CA 95201 Facility Phone#: 209-464-83 5 <br /> - - _ <br /> Legal Owner: ZUCKERMAN-HERITAGE INC dNew 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: Yes El No <br /> Men: Number of Toilets 8 Number of Showers 17 Number of Lavatories 12 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: <br /> Buildinss Employees Owner Owned NU-1/RV Buildings Employ <br /> D ees <br /> ormitories: <br /> Do Dwellings Owner Owned RR Cars <br /> SF Apartments MH/RV Spaces <br /> TOTAL of Both CoLuNm 0 0 <br /> Occupancy Dates: <br /> from 011/01/00 to 12 /31 /00 Crop Total Number or Days to be used this Calendar Year Ema <br /> from / / to / / Crop Total Days Occupied by 15 or more Employees <br /> ——— Note: Camps occupied by 15 or more esmp#o)ees for 60 ormnore a ar <br /> require a PxbNc Water System Permit. <br /> ❑ Inactive Imnnwtamst: In order to protect your land use status,tfcamp will not be used this year but isinteuded for use in theft Ckeekthis Box and return <br /> this application. <br /> Fee Schedule <br /> X Permanent Camp Annual Permit$35.00+Number of Employees 102 $12.00 each=S 1259. <br /> ❑ Orchard Camp Permit Fee=$95.00=S <br /> ❑ Transfer of Ownership=$20.00—S <br /> ❑ Permit Amendment=$20.00+Number of Additional Employees C$12.00 each=$ <br /> ❑ Late Application Fee$70.00+Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application TOTAL FEE DUE: 1259.00 <br /> REMrr TOTAL FEE AS CALCULATED ABOVE IN THE ENCLOSED Self-addressed ENVELOPE. iV4)W CHECKSPAYABLETO: PHS/EH;) <br /> Applicant agrees to all necessary Inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall <br /> be operated and maintained In accordance with the applicable provisions of the EMPLOYEE HOUSWC;ACT, Chapter 1,Part 1,Division 13 of the <br /> Ileahk and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code ofReguladons. x <br /> Applicant Name Zuckerman-Heritage, Inc. Title Coordinator 11Partnership ??Corporation <br /> (Please PRRMT or 7YPE) Address P.O. Box 487 Stockton CA 95 01 �,s� Phone 209-469-79 79 <br /> Applicant Signature 'DatE df Aption 12 06/99 _ <br /> Program Record ID# 27031Y Facility ID# 002963 Account ID# 0002525 <br /> Amount D tie of Payrncnt Payment pe QVS&PlP1#) <br /> Rec <br /> _Y <br /> -- <br /> Employee#: Acct# Fac ID 9-4 <br /> 01 PR#: PWS ID#: P/E, <br />