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oaquin County-Environmental Health Depa_ PAYMENT <br /> 1868 E. Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 RECEIVE® <br /> APPLICATION Nn Y 1 5 209 <br /> ENVIRONMENTAL HEALTH N JOAQUIN COUNTY SA <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTALHEALTH DEPARTMENT <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID M 0000460 <br /> *Additional Employees <br /> State ID#: 39-0120-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000120 <br /> Site Name: CANTON LABOR CAMP 39-120 Location: 13631 N HURD RD, LODI <br /> Operator: CANTON,ANTHONY <br /> Mailing Address: 2485 CENTRAL PARK DR, LODI CA 95242 Facility Phone#:(209)986-5341 <br /> Legal Owner: CANTON,ANTHONY New Owner? ❑Yes No <br /> Owner Address: 2485 CENTRAL PARK DR, LODI CA 95242 Owner Phone#:(209)986-5341 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes No <br /> Men: Number of Toilets f Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Emolovees <br /> Dormitories from Z 2 410 // / 2­1 Crop <br /> SF Dwellings from _/ / to_/ / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> 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 /> Permanent Camp Annual Permit Fee $50.00+ Number of Emplo ees A�e @$15.00 each=$ AZ yd- G1C> <br /> ❑ "transfer of Ownership i—Q,7 /aR K I r /Q!5K425.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional EmPloyees @$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE 2 g,*.,GY,� <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1, Part 1,Division 13 of the California Health <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name �A �,—ate Title 2��� ��� ❑Partnership <br /> (Please PRINT or TYPE) <br /> p ❑Corporation <br /> Address .2 yIP C'�yT/�'�L /�R, r,F �[) 9� 2Y Phone <br /> Applicant Signature Date of Application <br /> Amount Paid ate of Payment Payment Type Check/Receipt# Received By Account ID <br /> E 0000453 <br /> Facilit Program Record ID P/E Assigned to PWS ID <br /> FA0000454 PR0270120 2765 9819-BENIAMINE WA0515730 <br /> Report#:7066 Application Printed:11/13/2019 <br />