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oaquin County-Environmental Health Depart. <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) Annual Permit for Calendar Year 2-od <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 /> Co FacilitiesProvided b Camp: Community Kitchen? ❑ Yes No <br /> en: Number of Toilets ` Number of Showers Number of Lavatoriesen: Number of Toilets Number of Showers Number of Lavatories <br /> Occupancy Dates: <br /> Building Em IR ovees P <br /> Dormitories from / / / / 1 b to (Z-/--� // C G Crop k/ <br /> SF Dwellings from / / to /_/ Crop h/ <br /> Apartments /th7 4J <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: S - (' J ZQ16 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: E WA <br /> MH/RV Spaces ALTh EI1(T 1V7-V <br /> EAAt <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a y1A rllktfr <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 q f <br /> J9 Permanent Camp Annual Permit Fe( $35.00+ Number of Employees -7 @$12.00 each <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1, Part 1,Division 13 of the California Health <br /> and Safety Code and Chapter Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name j� ,yrl� �Qf� Title OU ❑ Partnership <br /> (Please PRINT or TYPE) Q �y� ❑• Corporation <br /> Address Phone kk /4aS <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Ch eceipt# Received By Account ID <br /> j 0002366 <br /> m Facility ID Progr Record ID P/E / Assigned to PWS ID <br /> FA0002805 PR0270040 2765 2089-SOOD WA0461354 <br /> Report#:7066 Application Printed:3123/2016 <br />