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I )aquin County-Environmental Health Departs P�iYMENT 1868 E.i,azelton Avenue-Stockton CA 95205-Phone: 209 +68-3420 RE!,CENED wlny 1 n 2014 APPLICATION SAN JOAQUP4 COUNTY EW ENVIRONMENTAL HEALTH DNMEHTAL HEALTHAL7H DEPARTMENT PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP C ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) $Annual Permit for Calendar Year 2-61+ ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID N: 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 JE No Owner Address: 23125 E LONE TREE RD, ESCALON CA 95320 Owner Phone#:(209)838-1297 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes No Men: Number of Toilets .b Number of Showers ,e' Number of Lavatories Women: Number of Toilets Number of Showers ,d- Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildines Employees DQ f Dormitories from / / zolstoAll I/ 2ol5 Crop •�' SF Dwellings from _/_/ to / / Crop Apartments 1 Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3,05 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 ScheduleQ o0 O. Permanent Camp Annual Permit Fe( $35.00+ Number of Employees @$12.00 each=$ `976, ❑ 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 �p TOTAL FEE DUE$ ! 3�- Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to FAD 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 Corte and Chapter 1,Subchapter 3,Title 2 Cali rnia Code of Regulations. Applicant Name F".vic J'J_ ] (' jQ Title ❑ Partnership (Please PRINT or TYPE) JJ [ICorporation Address 231 ?,s . ZV .e •� /�- CA1 /V 3 Z 0 Phone ZQlf_ �.?��/ Zg 7 Applicant Signature Date of Application ��- �— 2��• Amount Paid Date of Payment Payment Type C ec Receipt# Received By Account ID 3 3 0002937 7=FA0003360 cility ID Program Record ID PIE Assigned to PWS ID PR0515635 2765 2089-SOOD WA0515607 ReDort#:7066 Application Printed:10/15/2014