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/O v Joaquin County-Environmental Health Depp pmt 304 E Wei lvenue-Third Floor-Stockton CA 95202-PI 209468-3420 �✓' APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year ❑Amended Permit: -Change of Operator 'Change of Owner -Change of Operator Address -Change of Owner Address 'Additional Employees Permit ID#: 0010928 Please Note any Corrections or Changes in Facility/Operator Information directly on this Camp ID#: 3 9 . yrs Site Name: TOSTA#1 HENRY Location: 20662 SAN JOSE RD,TRACY Operator: HENRY&LINDA TOSTA Mailing Address: 20662 SAN JOSE RD,TRACY CA 95304 Facility Phone#:(209)836-1286 Legal Owner: TOSTA,HENRY&LINDA(#1) New Owner? ❑Yes ❑ No Owner Address: 20662 SAN JOSE RD,TRACY CA 95304 Owner Phone#:(209)835-0687 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No r Men: Number of Toilets Number of Showers Number of lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildines Employees Dormitories from 1 / I / Od' to I Z/i/ V q- Crop SF Dwellings l from to—I—/— Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces �.. Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Inactive a& t Require a PUBLIC WATER SYSTEM Permit ❑ TYu.�k.'✓ f'f�r-�Fy� 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. Fee Schedule ❑ Permanent Camp Annual Permit Fe $35.00+ Number of Employees @$12.00 each=$ Orchard Camp Permit Fee $95.00=$ t9 D. 0 D -W Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ late Application Fee $70.00+ Number of Employees @$24.00 each=$ . Fee must be submitted with Application TOTAL FEEDUES � �Q�. Ca Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter I, Part 1,Division 13 of the California Health and Safety Code and Chapter 1,,I$ubchapter 3,Title 25,California Code of Regulations. Applicant Name Lsl_;11L a� �� Title uj��eti ❑Partnership (Please PRINT or TYPE) Address -2-12[� ��,,, ^ , ,� 0 �^ `� ❑Corporation _ >�i l /�jt l.il�wf q l�3 �Y Phone ZO.?- i'C3lo-�L�('O Applicant Signature ^/ Date of Application Amount Paid Date of Payment Payment TypeCheck/R eipt# Received By Account ID -1b IQC ,0 tolvoL( ✓ �b91 0011126 Facility ID Program Record ID PIE Assigned to PWS ID FA0007393 PR0506396 2011 0018-TRINDADE N/A Report# 7066.tat '*-3Iq DD U-101t- see, _*ll Application Printed:4/2/2004