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PAYMENT RECEIVED San Joaquin County-Environmental Health Department MAR 2 8 2014 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 SAN JOAQUFN COUNTY ENVIRONMENTAL w QI! APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp []Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on this Camp ID#: �� y Site Name: rR k / Q C r Location: Cf CA/0 Al Operator: FA4wk /0, RoAq L / ,� q '7 Mailing Address:2325 /fie /s�.e-e (� G46N C1. Facility Phone Legal Owner: RNk �'lA New Owner? []Yes ❑ No Owner Address: Owner Phone#: Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ 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 I /41 / 1 U to 1'1 / 3 I/ILL Crop SF Dwellings 2 from —/—/—to—/ Crop Apartments OW L�K 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 TOTALSy- Camps occupied by 25 or more Employees for 60 or more days in a year C 4 ] ® 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 CC ❑ Permanent Camp Annual Permit Fee $35.00+ Number of Employees O @$12.00 each=$ ❑ Orchard Camp Permit Fee $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ Fee must be submitted with Application / 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, alifor is Code of Regulations. Applicant Name FRAAJ /(J, QC'Z Title DWAlelz fa'Partnership (Please PRINT or TYPE) /- �r ^A /,1 E]Corporation Address 2312s' Le Ne 'Tro /s(J� ef S`(R� l . AS ZCj Phone Applicant Signature Date of Application Amount Paid Date of Payment Payment Type ec elpt# Received By Account ID Facility ID Program Record ID PIE Assigned to PWS ID 1 ff Report#:7067.rpt Application Printed:6/9/2006