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S aquin County-Environmental Health Departr PAYMENT 1868 E.1_. elton Avenue-Stockton CA 95205-Phone: 20: -,8-3420 RECEIVED APPLICATION 206 ENVIRONMENTAL HEALTH 7AQUIN COUNTy R0NMEPERMIT TO OPERATE "E"AR ME EMPLOYEE HOUSING OR LABOR CAMP �Ec4RT1tENr ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) JK Annual Permit for Calendar Year 10/6 ❑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 ID#: 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 in No Owner Address: 23125 E LONE TREE RD, ESCALON CH 95320 Owner Phone#:(209)838-1297 Community Facilities Provided by Camn: Community Kitchen? ❑ Yes No Men: Number of Toilets Number of Showers Ar Number of Lavatories 'Jr Women: Number of Toilets Number of Showers Number of Lavatories iely_ Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories from l Z6 A to L/J1_/ZdA Crop 4:a z SF Dwellings from _/_/_to / / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 364' 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. Fee Schedule Q Q Permanent Camp Annual Permit Fet $35.00+ Number of Employees CE a,$12.00 each=$ _ 96 ❑ 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 a $24.00 each=$ Fee must be submitted with Application d6 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,Subchapter 3,Title 25,Cali ornia Code of Regulations. Applicant Name ARA AIk Al. ROC A Title Ow Ate^ tS Partnership (Please PRINT or TYPE) f/ / /� /j 9 ❑ Corporation Address ZbNe `71tee /W, 6rCh/b&j CA, 7.�JZa Phone Zdg 6.S'Z-4?fM Applicant Signature Date of Application Amount Paid Date of Payment Payment Type (Ch ec Receipt# Received By Account ID _D s 3 �(o / ?�,// � 0002937 Facility ID Program Record ID v PIE `J ](P Assigned to PWS ID FA0003360 PR0515635 2765 8987-SANGALANG WA0515607 Report#:7066 Application Printed:10/13/2015