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S taquin County-Environmental Health Departs PAYMENT RECEIVED 1868 E...i..zelton Avenue-Stockton CA 95205-Phone: 209-4t,8-3420 APPLICATION • ENVIRONMENTAL HEALTH SAN JOAOUIN COUNTY PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTI� ❑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 Permit ID 4: 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 No Owner Address: 23125 E LONF TREE RD, ESCALON CA 95390 Owner Phone#:(209)838-1297 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 Emolovees Dormitories from / _zxto 12, / / Crop LAI RY SF Dwellings from /_/ to_/ / Crop Apartments 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 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 M/Permanent Camp Annual Permit Fec $50.00+ Number of Employees @$15.00 each=$ ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees cr $15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees ct $30.00 each=$ Fee must be submitted with Application 7� o0 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,California Code of Regulations. Applicant Name Title L-1 • partnership (Please PRINT or TYPE) ❑Corporation Addresskd 0,01d. qW.0Phone( q,R�Q � 7 Applicant Signature , Date of Application 12" +•—I•q Amount Paid to Payment Payment Type Chec Receipt# Received By Account ID I) 1�IU- i l� `1 0002937 Facility ID Program Record ID P/E `-( Assigned to PWS ID FA0003360 PR0515635 2765 0016-HO WA0515607 Report#:7066 Application Printed:11/13/2019