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PAYMENT EI 10NMENTAL HEALTH DIVISI RIPOIFIVED 304 E WE,.__,2 AVENUE • THIRD FLOOR. STOCKTON, 95202 - (� 209/468-3420 MAY 12 19.7 APPLICATION �� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH PUBUC HEALTH SERVICES PERMIT TO OPERATE RMRONMENTAL HEALTH DIVM1014 EMPLOYEE HOUSING OR LABOR CAMP ,/ El New Camp ❑Conditional Permit L7 Annual Permit For Calendar Year ❑Amended e ❑Multiple Years(Permanent Housing Camps on(r) kat'e roved ©Change of Operato © Change of Owner ailed: ©Change of perator Address OO Change of Owner Address # ©Additional Employees ID# -$ Please Note any Corrections or Changes in Facility/Operator/Owner Information directly on this form - -- ----- - ---- ------- - ---- ------------------------------------------ I I Site Name: Location - ------ r -�� _----- --- Operator: L Mailing Address: Facility Phone#• f1/© Legal Owner: .New Owner El Yes N I Owner Address: —I � I5 < � Owner Phone#: -- ---------- ..� ��-;�t_ti__tom_ N� N- ---- - - -- 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: Build* Employees Build' s VEIes Dormitories: Owner Owned MH/RV SF Dwellings Owner Owned RR Cars Apartments MH/RV Spaces TOTAL of Both COLUMNS 0 0 Occupancy Dates:from 5/ / / q d to Crop L kSy Y%I S Total Number of Days to be used this Calendar Year from:f f/1j'A to /0/3;0/9B Crop A nA t AV 7 Total Days Occupied by 25 or more Employees Note: Camps occupied by 25 or more employees for 60 or more days 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 9 l ,Op r 11/ Permanent Camp Annual Permit$35.00+Number of Employees -73 @$12.00 each=$ f ❑ Orchard Camp Permit Fee=$95.00 $ Transfer of Ownership=$20.00 $ 1` v J , ❑ Permit Amendment=$20.00_I-Number of Additional Employees @$12.00 each= $ 1 `/ ❑ Late Application Fee$70.00+Number of Employees @$24.00 each=$ f17 9 �' Fee must be submitted with Application TOTAL FEE DUE: q_,4� 2 , EJTYOTAL FEE AS CALCULATED ABOVE IN THE ENCLOSED self-addressed ENVELOPE. MAKE CHECKS PAYABLE To: PHS/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 HousmrcACT,Chapter 1,Part 1,Division 13 of the Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name(please print or type) Title Address Phone Applicant Signature Date of Application Fee Amount Amount Paid Date of Payment Pa mentT 61 Check/Receipt# Received B is 7(-, Employee#: c Fac P PWS ID#: P/E: cVVateIDvccWatelD»