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rHYIVItN I San Joaquin County-Environmental Health Department RECEIVED 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 AUG 19 2022 APPLICATION SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ENVIRONMENTAL PERMIT DEPARTMENT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑ New Camp E]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) S/Annual Permit for Calendar Year!1n/��/� 1!Lt ❑ Amended Permit: "Change of Operator "Change of Owner llV"Vww— *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 NAND KATHY New Owner? ❑Yes N0 Owner Address: 23125 E LONE TREE RD, ESCALON CA 95320 Owner Phone#:(209)838-1297 Community Facilities Provided by Cama: 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 he Utilized this Year: Occu ancy Dates: Buildines Employees Dormitories from0/01 M2-2-.to / 14AO, Crop LAI RY SF Dwellings from _/_/ to_/_/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 4/ 6 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: NM/RV Spaces —� NSsg 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,ifcamp will not be used this year but is intended for use in the future,Check this Box and return this application. Fee Schedule Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$17.00 each=$ ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$34.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 186- 00 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,California Code of Regulations. Applicant Name � OW N- ROCHA Title C,��.�l�C�g PARTNER partnership (Please PRINT or TYPE) ❑b;1off' Address Phone, Applicant Signature Date of Application in-v-9-02Z Amount Paid Date of Payment Payment Type Check) eceipt# Received By Account ID NMI I� 0002937 Facility ID Program Record ID P/E I Assigned to PWS ID FA0003360 PR0515635 2765 0039-GOODERHAM WA0515607 Report#:7066 Application Printed:7/20/2022