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Sa..Joaquin County-Environmental Health Departmen. <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year_ <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#: 0010991 <br /> *Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000345 <br /> Site Name: ROCHA, FRANK N DAIRY#1 39-345 Location: 23243 E LONE TREE RD, ESCALON <br /> Operator: ROCHA, FRANK N <br /> Mailing Address: 23125 E LONE TREE RD, ESCALON CA 95320 Facility Phone#:(209)838-1297 <br /> Legal Owner: ROCHA, FRANK NAND KATHY New Owner? ❑Yes §/N0 <br /> Owner Address: 23125 E LONE TREE RD, ESCALON CA 95320 Owner Phone#:(209)838-1297 <br /> Community Facilities Provided by Camp Community kitchen? ❑ Yes 51 No <br /> Men: Number of Toilets y Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: �q <br /> Buildings Employee <br /> Dormitories from /1-M <br /> J I �lq to 1E��31 X0(9 <br /> Crop <br /> hAllcy <br /> SF Dwellings _� from /_/ to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3r5 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note PAYMME <br /> TOTALS ® ® Camps occupied by 25 or more Employees for 60 or more days in BF.PEIVED <br /> Require a PUBLIC WATER SYSTEM Permit 1 <br /> El Inactive 1320S <br /> 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.,;.,JOAomN c <br /> rY <br /> Fee Schedule ""orrnnTMENT <br /> [Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$15.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ <br /> Fee must be submitted with Application 1170. 00 <br /> TOTAL FEE DUE$ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1, Part 1, Division 13 of the California Health <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name MTHY Lo- KAIRMA Title L,P Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> AddressPhone ,R38.120 <br /> Applicant Signature L Date of Application M <br /> Amount Paid of F3ayment Payment Type Check/Receipt# Received By Account ID <br /> 1 `5, )3 ) � 7� 0002937 <br /> (Facility ID Program Record ID PIE ( / Assigned to PWS ID <br /> FA0003360 PR0515635 2765 8987-SANGALANG WA0515607 <br /> Report#:7066 Application Printed:11/9/2018 <br />