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San Joaquin County-Environmental Health Departmei., <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP �.{ �1 <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) I/H Annual Permit for Calendar Year <br /> ❑Amended Permit: 'Change of Operator 'Change of Owner l"' <br /> 'Change of Operator Address *Change of Owner Address Permit ID#: 0027506 <br /> *Additional Employees <br /> State ED#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH H)#: <br /> Site Name: MOTEL 6 Location: 2654 W MARCH LN,STOCKTON <br /> Operator: BARRERA,LUIS <br /> Mailing Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Facility Phone#:(831)229-0682 <br /> Legal Owner: RANCHHODRAI INC New Owner? ❑Yes ❑ No <br /> Owner Address: 4219 E WATERLOO RD,STOCKTON CA 95215 Owner Phone#:(831)229-0682Ext:LUIS <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes No <br /> Men: Number of Toilets , f Number of Showers Number of Lavatories l <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories 9 3 t u from /`/ to I / 3(/ J'3 Crop C No r"r o `G it tNvJ <br /> SF Dwellings from / to / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 1 IA <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces <br /> Note <br /> TOTALS '1 r7 l Camps occupied by 25 or more Employees for 60 or more days in a year <br /> I 6 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 in the future,Check this Box and return this application. <br /> Fee Schedule <br /> '7 1V L{ <br /> 'Ar Permanent Cam Annual Permit Fee $50.00+ Number of Employees @$15.00each=$ I U e <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUES "i+-}Q U <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Sett 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, 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 Lu ' �� r p i c- Title -1n/(G,✓ttc .�/ ❑Partnership <br /> (Please PRINT or TYPE) <br /> / // -_ Corporation <br /> Address t-7 Lf 5-0 iW4rl.(�r /-C S �l h S ��t�"d CA ��3 07 Phone 8121 , 221. 0 k;tS 2- <br /> Applicant <br /> Applicant Signature ��' Date of Application 0 i - 3Q . :3-3- <br /> Amount Paid Date of P ment Payment Type Check/Recelpt# Received By Account ID <br /> 0049218 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0025973 PRO545930 2755 9834-SUSZYCKI NIA <br /> Report#:7066 Application Printed:2/3/2022 <br />