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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 housing Camps only) ❑Annual Permit for Calendar Year__ <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> "Change of Operator Address 'Change or Owner Address Permit ID#: 0026139 <br /> "Additional Employees <br /> State ID#: <br /> EH ID#: <br /> Please Note any Corrections or Changes rn Facilitl`(7perulw'ln�,rnrcninrl,lir<<rlr or,his 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 0 No <br /> Owner Address: 101 E MAIN ST,HEBER CA 92249 Owner Phone#:(760)352-2364 <br /> Community-Facilities Provided by Camp: Community Kitchen? ❑ �✓ 'i <br /> Men: Number of Toilets 0 Number ofShowers 0 Number of Lavatories 0 <br /> Women: NumberofToilets 64 Number of Showers 64 Number of Lavatories 64 <br /> Housing Accommodations to be Utilixed this Year: Occupancy hates: <br /> Buildings Employees <br /> Dormitories 64 256 from 6, 23,2021, 10 01_,2021 Crop GARLIC <br /> SF Dwellings from _/_/ 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 /> MH/RV Spaces Note <br /> TOTALS 64 11 256 Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> ❑inactive PAYMENT <br /> Important: In order to protect your land use status,if camp wil0�1'y <br /> is intended for use tit the future,Check this Box and return this application REcEiVED <br /> e Schedule (1 A/ 1 <br /> M11Permanent Camp Annual Permit Fee 550.00+ Number of Employees @ S15.00 each=S JUN O <br /> ❑ Transfer of Ownership 525.00=S Aeulli.C 1,19TY <br /> ❑ Permanent Amendment Fee S2500+ Number of Additional Employees @ 515.00 each=5 ENVIRONMERN7AL <br /> ❑ Late Application Fee S100_00+ Number of Employees @ 530.00 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 F.HD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project (camp) shalt 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 of Regulations. <br /> Applicant Name ADRIAN GURROLA Title HOUSING COORDINATOR ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address 101 E MAIN ST, HEBER, CA. 2249 Phone 760-996-2252 <br /> Applicant Signature Date of Application f'&/O Z <br /> Amount Paid Date of P yment Payment Type Chack/Receipt# Received By Account ID <br /> 0046122 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0024661 PRO543451 2755 1420-NISSIM WA <br /> Report#:7066 Application Printed:11/19/2020 <br />