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PAYMENT <br /> RECEIVED <br /> MAY 12 2021 <br /> San Joaquin County-Environmental IIealth Department <br /> 1868 E.Hazelton Avenue-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 /> ❑Nc.v Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <br /> ❑Amended Permit: 'Change of Operator 'Change of Owner <br /> •Change of Operator Address aChange of Owner Address Permit ID#• 0026139 <br /> "Additional Employees -- <br /> State ED#: <br /> EH ID#: <br /> Please Note any Corrections or Changes in Favilirl-Operotor 6ti(ornialivil d&ect1yon thisforal. <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 a No <br /> Owner Address: 101 E MAIN ST,HEBER CA 92249 Owner Phone#:(760)352-2364 <br /> Commuum Farilitiex Provided by Camp:. Community Kitchen? ❑ Yes No <br /> Men: Number of Toilets 0 Number of Showers 0 Number of Lavatories 0 <br /> Women: Number of Toilets 64 Number of Showers 64 Number of Lavatories 64 <br /> liousing Accomnmdations to be Utilized this Year: Occutwncv Dal- <br /> -490-11im Emploveef <br /> Dormitories 64 256 fratrt _6i-_23!_2021t°_10;01/2021 Crop GARLIC <br /> SF Dwellirips from_/._._/_. to ( ! Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used dus Calendar Yea:: 100 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 100 <br /> M}I/RV Spaces Note <br /> TOTALS 64 256 Camps occupied by Z5 or more Employees for 60 or more days in s year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> Important: In order to protect your land use status,if camp will not be used this year but is intended for use m the future,Check this flex anti ret,rn:his application. <br /> Fee Schedule <br /> ❑ Permanent Camp Annual Permit Fee 550.00+ Number of Employees 256 @ S15.00 each=S $3'840'00 <br /> ❑ Transfer of Ownership $25.10=S <br /> ❑ Permanent Amendment Fee S25.00+ Number of Additional Employees @ S 15,00 each—S <br /> ❑ Late Application Fee SI00.00+ Number of Employees @ S30,00 each=S _ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUES $3'840'00 <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) sha0 be operated <br /> and maintained in accordance with the applicable provisions of the r,MPLOYEE 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 of Regulations. <br /> Applicant Name ADRIAN GURROLA Title HOUSING COORDINATOR ❑Partnership <br /> (Please PRINT or TYPEI - ❑Corporation <br /> Address 101 E MAIN ST, HEBER,CA.92249 Phone 760-996-2252 <br /> Applicant Signature Date of Application <br /> &)5 ob 7hQ x,' <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0046 122 <br /> Facility ID Program Record ID PIE .Assigned to PWS ID <br /> FA0024661 PRO543451 2755 1420-NISSIM N/A <br /> Report#:7066 Application Printed:11/19/2020 <br />