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01/03/200B 12:32 209464017 - ENVIRONMENTAL HEA1 ` PAGE 01/02 <br /> I+v— <br /> San Joaquin County-Environmental 11cnith Department <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209468-3420 q 2 5 <br /> APPLICATION 0 <br /> ENVIRONMENTAL IIEALTH 3 <br /> PERMIT TO OPERATE <br /> EMPLOYEE_HOUSING OR LABOR CAMP <br /> ❑New Camp ❑ Conditional Permit ❑ Multiple Years(rermancnt Bowing Camps only) ®Anniml Permit for Catemtar Year 2bo <br /> []Amended Permit: -Change of Operator 'Chasse of Owner <br /> 'Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID 9: <br /> Please Note arty CO"C010Rs or Changes in Factlily/Operaror Information directly on rhi.r Camp TD if: _ <br /> Site Name: +-�CjLocation: ! 7a 64 S f oG <br /> Operatnrc: <br /> Mailing Address: —JIlk <br /> ry <br /> )11 f,5,13tfacility Phone its. .• G C <br /> i <br /> Legal Owner: New Owner? ❑Ysa R No <br /> Owner Addresst C as. qt Owner Phone N: <br /> Community a rovided by a Community Kltchee: uye.1vu <br /> Men: NumbaofToiiets Number of Showers Number ofCavatoriet <br /> WOmm. Number ofToilcta Number efShowen Number ofLavaeorica <br /> Hous m Accommodation.ty be Utilized this Year. c Dstcs:j3uil m P�112YSA AWL-1 ?�ta`✓ L <br /> SF Dwell ?=thn�p <br /> DORr f-rem_/ J�to�/ /_Crop <br /> sl gngS t O <br /> Apatiments legal Number of Days to be used thisCalendar Year— 3 J <br /> Owner Owned MH/RV Total Days Oaeplt>d by 25 or mere Employees_ <br /> Owner Owned RR Cars Note. <br /> IOTA 8patxa Campn occupied by 25 or more employe m a <br /> es for 60 or ore days in year <br /> 70TAIS <br /> require a Public Water System Permit. <br /> l� <br /> ❑ .Inactive <br /> Imp-onant: In order to prntect your lend use atatlus,if camp will not be used this year but is intended for use in the futum Check tltix Box and return this application, <br /> Fee Schedule ! 3 <br /> Permanent Camp Annual Permit Fee: 535,00+ Number of Employees Q S12.00 cash-S <br /> Orchard Camp Permit Fee: $95.00-S <br /> Transfer of Ownerxhip: $20.00=S <br /> ❑ Permit Amendrnem Pet: $20.00♦ Number of AQ;onat Employes ® S12.00 each=S_ <br /> II��11 Late ApplitatienFees 970.00+ Numbcrommployees Q$24.00 each-S <br /> roe must be serOmltted swith Application <br /> TOTAL FEE DUE: S 10 141,60 <br /> Remit TOTAL.FEF, as CALCULATED ABOVE In the ENCLOSED Self-Addressed Envelope <br /> MAKE CHECKS PAYABLE TO: PUS-EHD <br /> Applicant agrees to ell necessary inipeetiona incident to i suanee of a PERMIT TO OPERATE Applicant agrees that this project(camp)shall be operated <br /> and maintalned In accordance with the applicable provisioni of the EMPLOYEE HOUSING ACT,Chapter 1.Part 1,Division 13 of the Calljornid lfeatelt <br /> and Sgjery Code end Chapter 1,Subchapter 3,Title 25,California Code of/tePularions. <br /> Applicant.Name �+ SYYIIa.� ef- SO>r'► G Title�rtvs t-`, ZL ❑Partnership <br /> (Please PRIM or rVPE)?O_7 / I ) + , ` <br /> Address Y L��411\ C� .�s�3� '�Corponrtion <br /> as9�-4, Q S 4r <br /> Applicant Signature Date Of Application <br /> Amount Pald TOnt Payment Type *C9lpt 0 Received By Account lD <br /> ��✓ ,-2� <br /> Fsellity ID Program Record ID PIE AS'toned 10 PWS ID <br /> Reoontt 7007 roi -�7/� <br /> (,yU/'TI�?GI /tL/D <br />