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aan Joaquin County-Environmental Health Depak___.,at PAYIW 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 R�c�'VlNr S elD JOAOUIN COUNT APPLICATION 2018 BAN NM RTML ENVIRONMENTAL HEALTH SAN JOAQU1 ENIvN ODEFA ENT PERMIT TO OPERATE FNVIRO N COUN N� EMPLOYEE HOUSING OR LABOR CAMP HEALTI1 p�AR MENr ❑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 Permit ID#• 0002797 *Additional Employees State ID#: 39-0040-EH Please Note any Corrections or Changes in Facility/Operator Information directly on thisform EH ID#: 39000040 Site Name: LARSEN RANCH 39-40/WATER SYSTEM Location: 5125 S KAISER RD,STOCKTON Operator: LARSEN, BARBARA Mailing Address: 21336 S MANTECA RD,MANTECA CA 95337 Facility Phone#:(209)823-9999 Legal Owner: LARSEN, BARBARA New Owner? ❑Yes ❑ No Owner Address: 21336 S MANTECA RD, MANTECA CA 95337 Owner Phone ih(209)823-9999 1 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildines Employees Dormitories from T/I/ 2d ko��_ �� Crop y&.rt&I_S' SF Dwellings from / / to /_/ Crop Apartments i Owner Owned M11/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 I GIB I Camps occupied by 25 or more Employees for 60 or more days in a year L_LJ 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 tZ @$15.00 each=$ .U► ❑ 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 f � 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 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 ubehapter 3,Title 2 ,California Code of Regulations. Applicant Name AWL Title a] fl(�y _ ❑ Partnership (Please PRINT or TYPE) b ❑Corporation Address � '� Phone Applicant Signature Date of Application G he Amount Paid Date of Payment Payment Type Check/Receipt# Received y Account ID II 71 3S� a�l_ 0002366 Facility ID Program Record ID PIE Assigned to PWS ID FA0002805 PR0270040 2765 2089-SOOD WA04613549 f 47 Report#:7066 Application Printed:10/23/2017