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S Paquin County-Environmental Health Departs. <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) LE3 Knnual Permit for Calendar Year---)( <br /> [:]Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#: 0002797 <br /> *Additional Employees <br /> State ID#: 39-0040-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000040 <br /> Site Name: LARSEN RANCH 39-40NVATER SYSTEM Location: 5125 S KAISER RD,STOCKTON <br /> Operator: LARSEN,BARBARA <br /> Mailing Address: 21336 S MANTECA RD, MANTECA CA 95337 Facility Phone#:(209)823-9999 <br /> Legal Owner: LARSEN,BARBARA New Owner? ❑Yes ® No <br /> Owner Address: 21336 S MANTECA RD, MANTECA CA 95337 Owner Phone#:(209)823-9999 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes []—'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: Occupancy Dates: <br /> Buildings Employees /� A <br /> Dormitories from /�/ �to 1/ Crop 00 /�'-V U lJt_ <br /> SF Dwellings from / / to—/ / Crop <br /> Apartments <br /> Owner Owned MH/RV 1 ( � Total Number of Days to be used this Calendar Year: J <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: �— <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> © Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> 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. <br /> Fee Schedule <br /> Cj--�ermanent Camp Annual Permit Fe( $35.00+ Number of Employees r @$12.00 each=$ L <br /> ❑ Orchard Camp Permit Fee Number of Employees l $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> [PA #AM n Fee $70.00+ Number of Employees @$24.00 each=$ <br /> RECEIVED Fee must be submitted with Application 1 (� <br /> TOTAL FEE DUE$ <br /> r -3 2 5 2015 Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EIID <br /> Applicakh 11 CCs--a,��'inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> andt �FnPLrt'rwith the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1, Division 13 of the California Health <br /> and Safety Code and Chap�er Subchapter 3,Title 25,C Iif rnia Code ojRegulations. <br /> Applicant Name ( , r) Title ❑ Partnership <br /> (Please PRINT or TYPE) �� ❑Corporation <br /> C <br /> Address Atone <br /> Applicant Signature !, 2� — q, Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> l l w 730 0002366 <br /> Facility ID Program Record ID �j PIE Assigned to PWS ID <br /> FA0002805 PR0270040 2765 8987-SANGALANG WA0461354 <br /> Report#:7066 Application Printed:2/25/2015 <br />