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C MENr <br /> RE <br /> San Joaquin County-Environmental Health Department EIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 MAY A v O <br /> 8 ?oto <br /> SAN JOAQUIN <br /> O <br /> APPLICATION ENVIRONMENTAL <br /> NVIRONMENT L <br /> ENVIRONMENTAL TO OPERATE <br /> HA <br /> PER ITTH DEpgRTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar Year 2019 <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID N: 0026139 <br /> *Additional Employees <br /> State ID#: <br /> EH ID#: <br /> Please Note any Corrections or Changes in Facilit lOperator Information directly on drys form. <br /> Site Name: FRESH HARVEST INC Location: 3951 BUDWEISER CT,STOCKTON <br /> Operator: GURROLA,ADRIAN <br /> Mailing Address: 101 E MAIN ST,HEBER CA 92249 Facility Phone#:(209)931-9341 <br /> Legal Owner: KHUSAL,MEERAN New Owner? ❑Yes ❑ No <br /> Owner Address: 101 E MAIN ST,HEBER CA 92249 Owner Phone#:(7$0)352-2364 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets 40 Number of Showers 40 Number of Lavatories 40 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occunancv Dates: <br /> Bulldines Employees <br /> Dormitories 160 from Q_E/_2,4_/2 019 to-1j_/3-�L/2 019 Crop GARL I C <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 )vote <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> 160 Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> Im aortani: 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 <br /> ® Permanent Camp Annual Permit Fee $50.00+ Number of Employees 160 @$15.00 each=$ 2,4 0 0.0 0 <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 <br /> TOTAL FEE DUE$ 2,4 5 0.0 0 <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 /> acrd Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name ADRIAN GURROLA Title HOUSING COORDINATOR ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address 101 E MAIN ST 22 <br /> Phone 760-352-2364 X.151 <br /> Applicant Signature Date of Application 2 <br /> Amount Paid ayment Payment Type Check/Receipt# Received By Account ID <br /> 0046122 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0024661 PR0543451 2755 1420-NISSIM N/A <br /> Recort#:7066 Application Printed:1119/2018 <br />