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1 <br /> REQ�ENr <br /> San Joaquin County-Environmental Health Department EIVE® <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 SAN i i 2022 <br /> SAN Jam,_ <br /> NVIRONTALAPPLICATION <br /> N <br /> ENVIRONMENTAL HEALTH HEALTH DEpARrti►ENT <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent(lousing Camps only) ❑Annual Permit for Calendar Year <br /> ❑ amended Permit: *Change of Operator *Chan;,,e of Owner <br /> 'Chauge of Operator Address *Change of Oe ner Address Permit lll#' 0000460 <br /> *Additional Employees <br /> State ID#: 39-0120-EH <br /> EH ID#: 39000120 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on thisform. <br /> Site Name: HJS SOLIS 39-120 Location: 13631 N HURD RD,LODI <br /> Operator: SOLIS-LUNA,HECTOR <br /> Mailing Address: PO BOX 1201,LODI CA 95241 Facility Phone#:(209)271-8360 <br /> Legal Owner: SOLIS-LUNA, HECTOR New Owner? ❑Yes ❑ No <br /> Owner Address: PO BOX 1201,LODI CA 95241 Owner Phone#:(209)271-8360 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets Number of Showers41 Number of Lavatories <br /> Women: Number of Toilets Number of Showers —� Number of Lavatoriesy <br /> Housing Accommodations to be Utilized this Year: Occunancy Dates: <br /> uildin s Emolovees <br /> Z2 >2 3.1 Z2 <br /> Dormitories from �/�/ to / / Crop <br /> SF Dwellings from _/_/ to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <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 � 1.� 7 <br /> Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$15.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ rj C <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE S Z�� <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 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name £'cro/Z- 564 ( L U�!/�q Title ❑Partnership <br /> (Please PRINT orTYPE)/ / Phone ❑CorporatioJn <br /> Address h l U��.0 L6 2 1_.A 7.S Z LZ 0 <br /> Applicant Signature Date of Application <br /> Amount Paid Date/of Payment Payment Type Check//Re/ eit# <br /> cei�pt# Received By Account ID <br /> sZto0.w I f I 2-� �17 13 64 <br /> 7 � o j l 0000453 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br />