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Sat,.toaquin County-Environmental Health Dep tlp PAYSE 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 RiL+ 0Vr CCCjV APPLICATION C 2018 ENVIRONMENTAL HEALTH SAN JO 1 PERMIT TO OPERATE ENVIc Qo COU EMPLOYEE HOUSING OR LABOR CAMP HEALTH AIMENTgNry ❑New Camp []Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Yea ARTMENT ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit W#• 0062797 *Additional Employees State ID#: 39-0040-EH Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000040 Site Name: LARSEN RANCH 39-40NVATER SYSTEM Location: 5125 S KAISER RD,STOCKTON Operator: LARSEN, BARBARA Mailing Address: 2133 95336 Facility Phone#. Legal Owner: LARSEN, BARBARA New Owner? ❑Yes ❑ No Owner Address: �; ��n.�T_�rn C* o��aI -fU Owner Phone#-J"O)8P9'9999-+ Community Facilities Provided by Camp: 1 Community Kitchen? ❑ Yes No Men: Number of Toilets ` �� Number of Showers 1 Number of Lavatories 1 Women: Number of Toilets Number of Showers Number of Lavatories Housing.%cconunodations to be Utilized this Year: Occupancy Dates: Buildines Employees / ! '6 Lf fin /1e�J� Dormitories from i of I A � � A Crop y SF Dwellings from _/_/ to_/ / 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 Require a PUBLIC WATER SYSTEM Permit ❑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 $50.00+ Number of Employees @$15.00 each=$ ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 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 Kith the applicable provis' of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and Safety Code and Chapter 1, bchapter 3,Title 25,Ca ifo nia Code of Regulations. Applicant Name Title Lo l _ ❑Partnership (Please PRINT or TYPE) (, ❑Corporation Address J Phone Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 0002366 Facility ID Program Record ID PIE Assigned to PWS ID FA0002805 PR0270040 2765 2089-SOOD WA0461354 Report#:7066 Application Printed:11/9/2018