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San Joaquin County-Environmental Health Department <br /> 1868 E.Ilazelton 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]lousing Camps only) ❑Annual Permit for Calendar Year <br /> ❑Amended Permit: -Change or Operator -Change of Omyner <br /> -Change or Operator Address -Change or Owner Address Permit M#• 0026139 <br /> -Additional Employees <br /> State ID#: <br /> EH ID#: <br /> Please More am•Corrections or Charges In Fecilin'Jpc r:uor h f trn eurion dircrdrat,this form. <br /> Site Name: FRESH HARVEST INC 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 4:(760)352-2364 <br /> Cnmmunim Facilities Prn ided by Came: Community Kitchen? ❑ Yes ❑� No <br /> Men: Number of Toilets 0 Number of Showers 0 Numberol'Lavatorics 0 <br /> Women: Number of Toilets 64 Number of Showers 64 Number of Lavatories 64 <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> BuildinaK Employee; GARLIC <br /> Dormitories 64 256 from 6/2312021%, 10/01 J2021 Crop <br /> SF Dwellings from _/_1__to_.._/_/_ Crop <br /> Apartments <br /> Owner Owned IvIH/RV Total Number of Days to be used this Calendar Year: 100 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 100 <br /> mi -1/RV Spaces Note <br /> Camps occupied by 25 or more Employees for 60 or more days in a year <br /> "TOTALS <br /> 64 256 Reouire a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive PAYMENT <br /> Important: In order to protect your land use status,if camp ell c-nns ye tis intrndrd for US-1 the future.Check this Box and rclum this application RF-CEIVED <br /> F cSchedulc JUN <br /> 1N 0 Q{T 2021 <br /> M-1Permanent Camp Annual Pcrmit Fee S50.00+ Number of Employees 51>.00 each=S ll <br /> ❑ Transfer of Ownership 325.00=S COUNTY <br /> F1 Permanent Amendment Fac S2500+ Number of Additional Employees @Z,515 00 each—S ENVIRONMERNTMENT <br /> HEALIM <br /> ❑ Late Application Fee $100.00+ Number of Employees ge S30 00 each=S <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE S <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE,to RI1D <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,Subcbapter 3,Title 25,California Code ofRegulafions. <br /> Applicant Name ADRIAN GURROLA Title HOUSING COORDINATOR El partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address 101 E MAIN ST, HEBER,CA. 2249 Phone 760-996-2252 <br /> Applicant Signature Date ofApplicatiion <br /> Amount Paid Of.of P yment Payment Type Check/Receipt# Received By Account ID <br /> 0046122 <br /> Facility Program Record ID P/E Assigned to PWS ID <br /> FA0024661 PRO543451 2755 1420-NISSIM N/A <br /> Report#.7066 Application Printed:11/1912020 <br />