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San Joaquin County-Public Health Services .0 Environmental Health Division 4 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP 7 ZNew Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) [1/Annual Permit for Calendar Year 200 z— ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: Please Note arty Corrections or Changes in Facility/Operator Information directly on this Camp ID#: r Site Name: J ` i a y( ii — 7v Location: / (, C l tl Operator: f Mailing Address: j� N �� ' R L l VdM Facility Phone#: ,2 0�) 9 j/- 2 Legal Owner: New Owner? ❑Yes P❑ No Owner Address: V -7-7 N �lf//i. L( L 0/n C�J / SZADwner Phone#: l(U 73 l- Communit y Facilities Provided by Cam Community Kitchen: LJ Yes NLJ Men: Number of Toilcts Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of lavatories llousine Accommodations to be Utilized this Year: Occunancy Dates: Butldin s Employees from /1/_92,to S/ 1 /OCCrop wfr k5� ft(PkS)UANA-s' . Dormitories 4from_/_/_to_/_/_Crop _ SF Dwellings Apartments Total Number of Days to be used this Calendar Year \ Owner Owned MH/RV Total Days Occupied by 25 or more Employees—P Owner Owned RR Cars Note: MH/RV Spaces Tun: .<< T— Camps occupied by 25 or more employees for 60 or more days in a year TOTALS require a Public Water System Permit. 0 ❑ Inactive 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 Fee: $35.00+ Number of Employees_ @ $12.00 each=$ ❑ Orchard Camp Permit Fee: $95.00=$ (('� Transfer of Ownership: $20.00=$ ❑ Permit Amendment Fee: $20.00+ Number of Alhtttional Employees @ $12.00 each=$_ �te Application Fee: $70.00+ Number of Employees IL @$24.00 each=$ Z)Fee must be mated with Application l0,00 2-1 l C{t,vo TOTAL FEE DUE: $ b L o t) Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope MAKE CIIECKS PAYABLE TO: PIIS ''-EHD L t° D-*u� 4ti-a ,q (I W/o a p.QhNti~j Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall he operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name WVEN A �O Title U W 4 C 2 ❑Partnership C [- (Please PRINT or TYPE) `'�Q ❑Corporation Address o�-1 N -�J �'C u C1 L3 Phone (I Applicant Signature Date of ApplicationZe Amount Paid Date of Payment Payment Type 1 Check/ eceipt# Received By Account ID J-(' a .oc-) -'/-?D/d a zlos%' 23 a3(, Facility ID Program Record ID P/E Assigned to PWS ID 137�4 51 �Eizi� Report#:7067.rpt Lim , d�3S2,G�j