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• PAYMr"NT ', )aquin County-Environmental Health Departs REC I. i /?-n 1868 E.ilazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 SAN JOAOUIN="'-Y APPLICATION ENVIRONMENlf,t_ ENVIRONMENTAL HEALTH HEALTH DEPARTMENT PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year 2-01-7 ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID# 0010991 *Additional Employees State ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH [D#: 39000345 Site Name: ROCHA,FRANK N DAIRY#1 39-345 Location: 23243 E LONE TREE RD, ESCALON Operator: ROCHA, FRANK N Mailing Address: 23125 E LONE TREE RD, ESCALON CA 95320 Facility Phone#:(209)838-1297 Legal Owner: ROCHA,FRANK N AND KATHY New Owner? ❑Yes C& No Owner Address: 23125 E LONE TREE RD, ESCALON CA 95320 Owner Phone#:(209)838-1297 Community Facilities Provided by Camn: Community Kitchen? ❑ Yes C' 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: Buildings Employees Dormitories from _/_/ to_/_/ Crop SF Dwellings from O/Ito /L/3!/ ZO/7 Crop A it aw 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. '45 r`L Fee Schedule ( s'.,-X) U1 Permanent Camp Annual Permit Fet $35,e0+ Number of Employees SLO_ @$ 0 each=$ 120. ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees a $12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees $24.00 each=$ Fee must be submitted with Application 65, 60 TOTAL FEE DUES 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 ACTT,Chapter 1, Part 1, Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25 Calif nia Code of Regulations. � Nk �f' Q Title Name n (Please PRINT or TYPE) /� ❑ Corporation Address Z3l ZS e_lo xe �fZQQ f I�TC/� (J0- �S 280 Phone �Z — !/n Applicant Signature Date of Application Amount Paid D to of Payment Payment Type Check/Receipt# Received By Account ID z1 0002937 �s-- Facility ID Program Record ID PIE Assigned to PWS ID FA0003360 PR0515635 2765 8987-SANGALANG WA0515607 Report#:7066 Application Printed:10/14/2016