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d�1 Joaquin County-Environmental Health Depart ,t <br /> 1868 E. Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 PAYMENT <br /> RECEIVED <br /> APPLICATION UK 2 9 2017 <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) XAnnual Permit for Calendar Yea- - fA <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 /> EH ID#: 39000345 <br /> Please Note anv Corrections or Changes in Facility/Operator Information directly on this form. <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 N AND KATHY New Owner? ❑Yes No <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 No <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Flousinf!Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildin¢s Employee s <br /> Dormitories from // ao / 07 A�&Rm Crop LAIRY <br /> SF Dwellings from / / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> Imnortant: 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. <br /> Fee Schedule 120.O V <br /> Permanent Camp Annual Permit Fee $50.00+ Number of Employees cr $15.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees a.$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees (c:�$30.00 each=$ <br /> Fee must be submitted with Application TOTAL FEE DUE$ 170-00 <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 ENIPLOYEE HOUSING ACT,Chapter 1, Part 1, Division 13 of the California Health <br /> and Safety Code and Chapter I,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name ,��l�N�oeH Title OWNER torporation <br /> artnership <br /> (Please PRINT or TYPE) n� 1 t (���z~�+n <br /> Address 23125_E. .ONE IEEE M ES0A0AUM a�,,,L11 • 1&]21.1/ Phone�q��a- qz I D <br /> Applicant Signature Date of Application <br /> Amount Paid Jbate of Payment Payment Type Check/Receipt# Received By Account ID <br /> 170 - a a 5 G / q 0 O 3�'7 0002937 <br /> Facility ID Program Record ID P/E `Assigned to PWS ID <br /> FA0003360 PR0515635 2765 8987-SANGALANG WA0515607 <br /> Report#:7066 Application Printed:10/23/2017 <br />