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PAYMENT <br /> RECEIVED <br /> San Joaquin County-Environmental I lealth Department <br /> 1868 E.I lazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 APR 2 8 2020 <br /> APPLICATION <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ENVIRONMENTALHEALTH HEALTH DEPARTMENT <br /> PERMITITTOTO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent(lousing Camps only) ❑✓ ,Annual Permit for Calendar Year 2020 <br /> ❑Amended Permit: "Change of Operator "Change of Owner <br /> *Change of Operator Address "Change of Owner Address Permit ID#: 0026139 <br /> ".Additional Employees <br /> State I[)#: <br /> Ell ID#: <br /> Please Note any Corrections or Changes in Facilin�/Operator Information directly on Ihi.s fnrnl. <br /> Site Name: FRESH HARVEST INC /y Location: 3951 BUDWEISER CT.STOCKTON <br /> Operator: Mar 1('\ V%Itn6oza <br /> Mailing Address: 101 E MAIN ST,HEBER CA 92249 Facility Phone 0:(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 /> Community Facilities Provided by Cama: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets 64 Number of Showers 64 Number of Lavatories 64 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> /lousing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildinas Emplovees <br /> Dormitories 255 from 06/25/20 ,. 10/15/20 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: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> 255 Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> Imnortant: In order to protect your land use status,if camp will not be used this year but is intended for use in the future,Check this Bos and return this application. <br /> Fee Schedule <br /> ❑✓ Permanent Camp Annual Permit Fee $50.00+ Number of Employees 255 r;$15.00 each-S 3825.00 <br /> ❑ Transfer of Ownership $25.00- S <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees to,$15.00 each-S <br /> ❑ Late Application Fee $100.00* Number of Employees a$30.00 each ti <br /> Fee must be submitted with Application <br /> TOTAL FEE DUES 3875.00 <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CIIECKS PAYABLE to FAID <br /> Applicant agrees to all necessary inspections incident to issuance of :t PERMIT TO OPERATE. Applicant agrees that this project (camp) shall he operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT, Chapter I, Part I, Division 13 of the California Health <br /> and Safep,Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name Maria Mendoza Title H2A Housing Coordinator, ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address 101 E Main S�t Heber CA 92249 Phone(760)592-2307 <br /> Applicant Signature I%/�/v Q Date of Application q t Z, /W ZV <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> �U Odo <br /> 0046122 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0024661 PR0543451 2755 1420-NISSIM N/A <br /> Report#:7066 Application Printed:4/3/2020 <br />