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to Joaquin County-Environmental Health Dep, ;nt 1861, Hazelton Avenue-Stockton CA 95205-Phone. �468-3420 PAYMENT APPLICATION APR L b 2 0 17 ENVIRONMENTAL HEALTH f` PERMIT TO OPERATE SAN JOAQUA COUNTY EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMEN ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit WF6k[bb$ 7_ ❑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 this form. EH ID#• 39000040 Site Name: LARSEN RANCH 39-40MATER SYSTEM Location: 5125 S KAISER RD,STOCKTON Operator: LARSEN,BARBARA Mailing Address: 21336 S MANTECA RD,MANTECA CA 95337 Facility Phone#:(209)823-9999 LegalO�$ner: LARSEN,BARBARA New Owner? ❑Yes KNo O�rner.kddress: 21336 S MANTECA RD,MANTECA CA 95337 Owner Phone#:(209)823-9999 (ommunils Facilities Provided by Camp: Community Kitchen? ❑ Yes No Nien: Number of Toilets I 0 Number of Showers ` (�D Number of Lavatories t l 1 N%omen: Number of Toilets Number of Showers Number of Lavatories Ilousing Accommodations to be ITtilized this Year: OccupaneN Dates: 13uildina.c Emolovees / / f / ! —7 to 3 1 1-7 Dormitories from / Crop b-Lf._,( SF Dwellings from —/—/—to_/ / Crop Apartments _ Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3 to S 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 I nt n o rta nt: In order to protect your land use status,if damp will not be used this year but is intended for use in the future,Check this Box and return this application. Fee Schedule is t"a ❑ Permanent Camp Annual Permit Fet $3�+ Number of Employees @$J2:60 each=$ S 7 c v ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ 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 A$24.00 each=$ �T 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 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,Michapter ,Title 25,C li rnia Code of Regulations. Applicant Name Title C� ❑ Partnership (Please PRINT or TYPE) ❑Corporation Address o'j ikD-'t2- Phone R?-a "7��,' Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID I'sQ , � (2 la I ! % k>'��Z 1 (L� 0002366 LA Facility ID Program Record ID P/E Assigned to ✓ PWS ID FA0002805 PR0270040 2765 2089-SOOD WA0461354 Report# 7066 Application Printed: 10/14/2016