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l V <br /> S JOAQUIN COUNTY a PUBLIC HEALTH",ERES 11A`' `l�gR�r�1-( <br /> ENVIRONMENTAL HEALTH DIVISIONpl':t'[ <br /> 304 E WEBER AvENUE a THIRD FLOOR a STOCKTON CA 95202 a Phone: 209/46I J420 _ <br /> r J M��1 2D <br /> APPLICATION f <br /> ENVIRONMENTAL HEALTH S/ N Bbl IC MAQUINEALTH SORVI ES <br /> PERMIT TO OPERATE ENVIRONMENTAL HEALTH DIVISION <br /> EMPLOYEE HOUSING OR LABOR CAMP.- <br /> Now <br /> AMPNew Camp ❑Conditional Permit Annual Permit For Calendar Year <br /> ❑Amended Permit ❑Multiple Yean(Permanent.Housing Camps owly) ate Approved <br /> • Change of Operator -Change of Owner ate Mulled: <br /> • Change of Operator Address • Change of Owner Address ermlt# <br /> • Additional Employees lampID# .. <br /> Please Note any Corrections or Changes in FacUftylOperatorlOwner Information directly on this form. <br /> Site Name: CASTELANELLI BROS Location: 37 W ARMSTRONG RD <br /> Operator: CASTELANELLI BROS <br /> ----------------------------------------------------------------------------------------------------------------------------------- ----------- --------------------------------------------------------------------------------------------------------- <br /> Mailing Address: 401 W ARMSTRONG RD,LODI CA 95240 Facility Phone#: 209-369-9218 Lair, <br /> Legal Owner: CASTELANELLI BROS anew Owner ❑Yes &d' <br /> Owner Address: 401 W ARMSTRONG RD,LODI CA 952 Owner Phone#: 209-369-9218 <br /> Community Facilities Provided by Camp: Community Kitchen: ❑Yes 0 No <br /> Men: Number of Toilets 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: <br /> Bull dlnxs Employees Bundbsn Employee <br /> Dormitories: Owner Owned MH/RV <br /> SF Dwellings Owner Owned RR Can <br /> Apartments NEWRV Spaces <br /> TOTAL of Both COLUMNS <br /> Occupancy Dates: <br /> from <br /> from to Crop Total Number of Days to be used this Calendar Year <br /> Ilrom ! / is Crop Total Days Occupied by 23 or store Employees <br /> ——— ——— Note: Camps occupied by 23 or stare employees for 60 or score drO+s a year <br /> require a Pxb&Water System Pena& <br /> ❑ Inactive L In order to protect your land use statin ifcan p will not be used this year bid tr6steAdedjor are in Me,/i*m CAwck this Box and return <br /> this appucaam <br /> Fee Schedule <br /> ❑ Permanent Camp Annual Permit$35.00+Number of Employees $12.00 each—S <br /> 95- <br /> a ❑ Orchard Camp Permit Fee=$95.00=S <br /> ` '� ❑ Transfer of Ownership=$20.00=S <br /> ❑ Permit Amendment=$20.00+Number of Additional Employees @$12.00 each=$ <br /> *ate ❑ Late Appticatlon Fee$70.00+Number of Employees @ <br /> $24.00 each=$ <br /> SAN ioA�;U1N ;V10E5 <br /> \J1 uBUC I!Ea� F'•,ETN nNIS1�1 Fee must be submitted with Appdcatlon TOTAL FEE DUE: <br /> Rc)tIMct, <br /> Roar TOTAL FEE As CALCULATED ABovE IN THE ENCLOSED sear addressed ENVELOPE. 11I4/m CHROMPAPABLE To: PHS/FHD <br /> i Applicant agrees to all necessary inspections Incident to issuance of a PEw=To OPERATE. Applicant agrees that this project(camp)shad <br /> be operated and maintained in accordance with the applicable provisions of tlX EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the <br /> HeaA*and Safely Code and GLapter 1,Subchapter 3,Title 25,California Code Of Regulations. <br /> Applicant Nam n Title O 4jn., /�� ElPartnership ❑Corporation <br /> (Please PRINfor TYPE) Address 't /C PhoneaQ.9-36-ga /1 <br /> Applicant Signature Date of Application <br /> Program Record ID# 2000'70 Facility IIT# 003431 Account ID# 0003008 <br /> Meant Paid I Date of t payment T t# I Received <br /> / !?0 S 6 3 <br /> Employee A Kcd#k Fac ID: PR* PWS IDB: P/E: <br />