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-+AN .IOAQUIN COUNTY a PUBLIC HEALTH __RVICES ENVIRONMENTAL HEALTH DIVISION 304 R WFIIFR AVFNUE a THIRD FLOOR a STOCKTON CA 95202 a Phone: 209/468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP (J Now Camp ❑Conditional Fermi Annual Permit For Calendar Year U Amended Pernik. ❑Multiple Years(Permanent!loosing Camps on(r) Date Approved • Change of Operntor -Change of owner Ditto Maned: • Change of Operntor Address • Change of Owner Address ermlt# • Additional Employees :amp 1D# Please Note any Corrections or Cha es In Facile O eralorrolrner Information directly on this form. Site Name: ROCHA,FRANK N DAIRY3q_3y` Location: 2324 E LONE TREE RD — — - —__ - -- -- -- ---- --------- _ —.---------------------------------------- Operator: ---------Operator: FRANK N ROCHA Mailing Address: 23125 E LONE TREE RD,ESCALON CA 95320 Facility Phone#: 209-838-2521 — --- -- __ —- ---- ----- -- ----- - -- ----------------------_--- ----------- Legal Owner: ROCHA,FRANK New owner 11Yes El Na) Owner Address: 23125 E LONE TREE RD,ESCALON CA 95320 Owner Phone#: 209-838-2521 Community Facilities Provided by Camp: Community Kitchen: ❑Yex ❑No Men: Number of Toilets Number of ShowersNumber of Lavalorlox Women: Number of Tollets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Bulldlnss Employees Bundlers Emplorexs normlMrtos: OwnerChvnedNlH/RV — -- SF Dwellings owner Owned RR Can Apartments MTURV Spaces -- - TOTAL of Both COLIfMNS Occupancy Dates: from_�—/_to_�_!_Crop Total Number of Days to be axed this Calendar Year "M / to /_/ Crop Total Days Occupied by IS or neore Employees —— — Note: Camps occupied by 25 or wear em#awec for 60 or more dans agar require a Pw6Nc Mager Sysfem Peri[ ❑ Inactive ( In order to protect your land use status,tf canp will not be used thus year but isialmdedJbr use i"4Ye f ttw v,Check this Bax and return flys 1wWraUon �y Fee Schedule ❑ Permanent Camp Annual Permit$3'_5.00 i Nnmbor of Ymployees $12.0)each—S Orchard Camp Permit Fee=$95.00=S DEC 72, l_) Transfer orownershtp=$20.00-4 ❑ Permit Amendment.=$20.00+Number of Additional F,mployeex _ _.__ (tri$12.00 each t )t ',.09114 COU14TY 5FWlt",r.-S 11 Late Application Fee$70.00+Number of F.mployeex a $24.00 each=$ — 141'dh�)NMFNTAL K.AI.TH t~tVI5100 Fee must be submitted with Application TOTAL FEE DUE: $� Pi art i TOTAL FEE AS('ALCITA-ITf)AINIFE IN 7111,FNCL08FD SCIf 'Idd1'essed ENVELOPE. Af4AT CiiE(,Kz PAi iBr.r ro: PTIS/ETTT) Applicant agrees to all necessary Inspections incident to Issuance of a PERNfrrTOOPERATE. Applicant agrees Ihat this project(camp)shall be operated and maintained In accordance with the applicable provisions of the Fmpi.oYEE 11OUSMG ACT,Chapter 1,Part 1,Division 13 of the Heahh and Safety Cade and Chapter 1,Subchapter 3,This 25,California Corm efRegulations. Applicant Name F;2AA4 II/ 1'1O(.)7A ,rlrTltiee�-) 1!1J Pn 'Pwtarenhlp ❑Corporation (Please PRW or ME) Address G.3/G� C GUti'r y (bZ eJCR/be, A-SZO Phone Applicant Signature 'ef1_ Date of Application /Z-/6-�fG- Program Recor 200119 Facility ID# 003360 Account ID# 0002937 Amcwt Paid Date f Payment Payment Type 54V&JReceJpt# Received By Employee 9: --Accl W F ID: PR B: PWS IDB: 77 PIE: