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San Joaquin County-Environmental Health Department <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 Hawing Camps only) ❑Annual Permit for Calendar Year <br /> ❑Amended Permit: Change or Operator •Change of Owner <br /> "Change of Operator Address 'Change of Owner Address Permit ID#• - 0026139 <br /> "Additional Employee <br /> State 1D#: <br /> Please Note aN;tCorrectiotts or Clitmgaslit C�rillt}'t7prt:crtarltfotnidtlr�n rlh'xalTi'arr thicform. EH ID#: - <br /> Site Name: FRESH HARVEST WC Location: 3951 BUDWEISER CT,STOCKTON <br /> Operator: MENDOZA,MARIA <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#:(760)352-2364 <br /> _r an mlm!1v:Faciiiti"PtroVided bi QtWn: Community Kitchen 7 ❑ Yea [�No <br /> Men: NumberofToilets 0 Number of Showers 0 Number of Lavatories 0 <br /> Women: NumberofToilets 65 Number ofShowers 65 Number of mtories 65 <br /> dloirvrn rtectimiitadnHons O be Util iqd thityieur`; Occunanty Dates: <br /> 1:.. ;E....a.e. <br /> 13 it n mpl r ea <br /> Dormitories 65 260 from 06/25/2022 to 09/22/ 2022 Crop GARLIC <br /> SF Dwellings from / / to /_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year. 89 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 89 YMENT <br /> Mll/RV Spaces --�'ti EI VED <br /> Note <br /> MAY 1 1 <br /> TOTALS 65 26� Camps occupied by 25 or more Employees for 60 or more days in a year 2022 <br /> Require a PUBLIC WATER SYSTEM Permit <br /> El Inactive <br /> SAN JOAOUIN COUNTY <br /> 111[pattlult In order to protect your land use status,if camp will not be used this yeu but is intended for use in the future,Check this Box and retum this application. ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> F..Sur ehedn_Ic <br /> ❑ Permanent Camp Annual Permit Fee 550:00+ Number of Employees 260 @$15,00 each=$ $3,840.00 <br /> ❑ Transfer of Ownership 525..00=S <br /> ❑ Permanent Amendment Fee $2500+ Number of Additional Employees a S15,00 each-S <br /> ❑ Late Application Fee S10000+ Number of Employees C 530,00 each—5 <br /> Fee must be submitted with Application $3,840.00 <br /> TOTAL FEE DUES <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 afRegulations. <br /> Applicant Name ADRIAN GURROLA Title HOUSING COORDINATOR ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address 101 E MAIN ST, HEBER, CA. 92249 Phone 760-996-2252 <br /> Applicant Signature Date of Application nAccount <br /> Amount Paid ate of Payment Payment Type Check/Receipt# Received By!lf/Facility ID Program Record ID P/E Assigned to PRO543451 2755 1420-NISSIM <br /> Report#:7066 � �R ll Application Printed:1111912020 <br />