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c)01/03/2008 12: 32 20946401-- ENVIRONMENTAL HEAT - i PAGE 01/02 San Joaquin County.Environmental Hellish Department 304 E Weller Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 APPLICATION ENVIRONMENTAL IIEALTH .3 0 PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP❑New Camp ElConditional Permit ❑ MnlBple Years(Ptrmarent Housing Camps only) ®Annuxl Permlt for Calendar Year 26t7O p/ ❑Amended Permit: 'Change of Operator 'Change of Owner 'Change of Operator Address 'Change of Owner Asldrrss 'Additional Employees Permit ID#: Please Note any Corrections or Changes in Facility/Operafor Information directly on rki.r ICamp ID N: g !� Site Name: CG f,ocatlon: 1 ?41a S Operator:. Mailing Address: r S acility Phone M: .. 5 G 6 i Legal Owner: Ne-Owner 7 Yea No Owner Address: lilol e- as a>q 0 C Owner Phone a: ak Community a rovided h s Community Kitchen: YctN Men: Number ofToiltLs NumberofShowers Number ofLavatonet Women: Number of Toilet+ Number of Showers Number of Lavaoones Housing Accommodations tq be Utilized this Year: ccu Dstcs: %��,,'� _B2 l" d n �1Qxis-1 {�qj�t 7 to Z`�� 0 V W4l DF DwellIn from—/�_to`t_t_Clcp gs Apartments Total Number of Days to be used Ihb Calendar Ytar. Owner Owned WiRV Total Days Occapicd by 25 or more Employees_ 41,7 49-4 4C Owner Owned RR Cars Note: MFVRV spaces Camps occupied by 25 or more employees for 60 or more days in a year TOTAL¢ r� require a Public Water System Permit. I� ❑ Inactive impo ant: In order to protect your land use ntaruc,if camp will not be used this year but is intended for use in the future•Check du-.Box and return this application, Fee Schedule t ❑Permsntnt Camp Annual Permit Fee: E3S.00+ Number of Employees $12.D0 each-S ❑ Orchard Camp Permit Fee_ 595.00-S nn Transfer of Ownership: $20,00=S ❑ Permit Amendment ret. E20.00 4 Number of Agional Employccc ® $12.00 each-S- ID Late Application Fee: E70.00+ Number orEmployees Qn $24.00 each-S Fee must be Qmltted with Application TOTAL FEE DUE: S Remit TOTAL,FEE, as CALCULATED ABOVE In the ENCLOSED Self-Addressed Envelope T MAKE CHECKS PAYABLE TO: rHS•EHD Applicant agrees to all netessary inspections incident to ieauance of a PERMIT TO OPF.RATF Applicant agrees that this project(camp)shall be operated and maintained In accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1.Tart 1,Division 13 of the Catffornia Ifealih aad Safety Cpde and Chapter 1,Subchapter 3,Title 25,California Code of Regutar ons. Applicant Name A t `,Q YY1 ba d Ob'1 �. Title z t Q ❑Partnership (Please PRINT or TYPE)�O ^ t, _ —7�� ` �/ Corporation Address ! 'v t1/1C�QY1 iCC 9J bout G� q !aa Applicant Signaturr Date of Application Amount Pald Daft of Payment Payment Type ,CChoocck/RRacaipt 4 Received By , 1 Account ID Facility ID Program Record ID PIE Assigned to PWS ID Reuon V 7067 roi