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PAYMENT <br /> RECEIVED <br /> MAY 12 2021 <br /> San Joaquin County-Environmental Health Department <br /> 1868 E.HRZCItonAvenue-Stockton CA 95205-Phone: 209-468-3420 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annunl Permit for Calendar Year <br /> ❑Amended Perm it: -Change or Operator "Change of Owner <br /> "Change of Operator Address "Change of Owner Address Permit ID 4: 0026139 _ <br /> `Additional Employees <br /> State ID>`?: <br /> EH ID 4, <br /> Please Note arrr Corrections or Change's to FacilipsOFerptor brf-or iialion( rectlron thisform. <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 V:(209)931-9341 <br /> Legal Owner: KHUSAL,MEERAN New Owner? ❑Yes z] No <br /> OLrner Address: 101 E MAIN ST,HEBER CA 92249 Owner?bone 9:(760)352-2364 <br /> Community Far'litie3 Provided by Camn:. Community Kitchen? ❑ Yes No <br /> Men: NumberofToilets 0 Number of Showers 0 Number of Lavatories 0 <br /> Women: Number of Toilets 64 AhrnberofShoscers 64 Numhcrofi.ovatories 64 <br /> Ilousine Aeromnmdations to be Utilized thk Yenr:. Occupancy D.,(-, <br /> Buildino EmnlaveC.c p GARLIC <br /> Do,mitorics 64 256 from 6i 23!202110 10;01/2021 ('rp <br /> SF Dwcllinits from _/_/ to_.—./--/— Crop <br /> Aparmnents <br /> Owner Owned MIA/RV Total Number of Days to be uscd skis Calendar Yea. 100 <br /> Owner Owned RR Cas Total Days Occupied by 7.5 or more Employecst 100 <br /> MH/RV Spaces Note <br /> Camps occupied by 25 or more Employees for 60 or more days in s veer <br /> TOTALS <br /> 64 256 Reauire a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> Intnor untr To order to protect your land use status,if camp wilt not be used this year but is intended ter use m tie fuhnc,Check this Box mid tetum:his application. <br /> Fee Schedule <br /> ❑ $3,840.00 <br /> Permanent Camnn <br /> Camp Annual Permit Fee S50,00+ Number of Employees 256 <br /> ❑ T:utsfer of Ownership 525.00=S <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @ S 15,00 each—S <br /> ❑ Late Application Fee S100-00+ Number of Employees @ S30,00 each-S <br /> Fee must be submitted with Application $3,840.00 <br /> TOTAL FEE DUR S <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED SCH-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, Chipte- I, Part 1. Division 13 of the California Health <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name ADRIAN GURROLA Title HOUSING COORDINATOR 0 Partnership <br /> (Ploase PRINT or TYPE) ❑Corporation <br /> Address 101 E MAIN ST, HEBER, CA.92249 <br /> Phone 760-996-2252 <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Reccipt x Received By Account 10 <br /> � �0 0046,22 <br /> Facillry ID Program Record 10 PIE Assigned to PWS ID <br /> FA0024661 PRO543451 2755 1420-NISSIM NIA <br /> Report#.7066 Application Printed:1//1912020 <br />