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PAYMENTJoaquin County-Environmental Health Depart) RECEIVED 18b6 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-4o6-3420 rrr. A A APPLICATION SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ENVIRONMENTAL PERMIT TO OPERATE HEALTH DEPARTMENT EMPLOYEE HOUSING OR LABOR CAMP �{ E]NewCamp [-]Conditional Permit E] MultipleYears(Permanent Housing Camps only) I/t1 Annual Permit for Calendar Year `` GL E]AmendedPermit: `Change of Operator 'Change of Owner l—" *Change of Operator Address *Change of Owner Address Permit ID#: 0027506 *Additional Employees State ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on this farm. EH ID#: Site Name: MOTEL 6 Location: 2654 W MARCH LN,STOCKTON Operator: BARRERA,LUIS Mailing Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Facility Phone#:(831)229-0682 Legal Owner: RANCHHODRAI INC New Owner? ❑Yes ❑ No Owner Address: 4219 E WATERLOO RD,STOCKTON CA 95215 Owner Phone#:(831)229-0682Ext:LUIS Communitv Facilities Provided by Camp: Community Kitchen? ❑ Yes XNo Men: Number of Toilets , Number of Showers Number of Lavatories 1 Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees tJ Dormitories from =1/ / to Crop C k r'r Q S I c 1-`uv%_1 SF Dwellings from —/—/—to—/—/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: ,LA Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 1 LA MH/RV Spaces Note TOTALS l r7 Camps occupied by 25 or more Employees for 60 or more days in a year I b Require a PUBLIC WATER SYSTEM Permit ❑Inactive Important: 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 Box and return this application. Fee Schedule 0 �1 o Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$15.00 each=$ LA t ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee S25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee.n.[st bp snbmltted with Annlication TOTAL FEE DUE$ �t�C: Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project (camp) shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT, Chapter 1, Part 1, Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name Ly/ ` 1 0 a )z ❑Partnership (Please PRINT or TYPE) ❑Corporation Address t 7 y 5_0 Av4.-1. e4-• AV) R 1 h s 5th t n«d LA 3-iL1I Phone 8,?l 22 yy L Ss 2 Applicant Signature Date of Application 0/ 30 } Amount Paid Date of P ment Payment Type Check/Receipt# Received By Account ID 00/. n 0049218 Facility ID Program Record ID r PIE / Assigned to PWS ID FA0025973 PRO545930 2755 9834-SUSZYCKI N/A Report#:7066 Application Printed:2l3/2022