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I Joaquin County-Environmental Health Depart) PAYMENT" 18bo L.Hazelton Avenue-Stockton CA 95205-Phone: 209-408-3420 RECEIVED APPLICATION JUN 10 2020 ENVIRONMENTAL HEALTH PERMIT TO OPERATE SAN JOAQUIN COUNTY /EMPLOYEE HOUSING OR LABOR CAMP { ENVIRONMENTAL New Camp [:]Conditional Permit Multiple Years(Permanent Housing Camps only) ❑Annual Perm,il�or'CaRrn�aPr"S"e3r MENT ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#• *Additional Employees State ID#: EH ID#: Please Note any Corrections or Changes in Facility./Operator Information directly,on this furan. Site Name: 140{ 6 Location: 246(464- W.-C1, Ckk e ckZ" Operator: �i �YZ P"*.k Mailing Address: 1oqV CSO S 4-6 yt,�n�s a3 G� Facility Phone#: Legal Owner: ASMV i No Q'/ fNa- New Owner' ❑Yes ❑ iW Owner Address: 2 -r fi✓• �v"►" i L"K'< t✓W�rt CIA- qTZ O T Owner Phone#: Community Facilities Provided by Camra: Community Kitchen? ❑ Yes [2--No 2 Men: Number of Toilets 35 Number of Showers 3J Number of Lavatories 35 Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildiinnes Emmlovees Dormitories c�JS from 6 / Sl to L� I Crop z CAA,—",u SF Dwellings from / to Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: ` Owner Owned RR Cars Total Days Occupied by 25 or more Employees. ` MH/RV Spaces Note TOTALS ' Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive Important: In order to protect your land use status.if camp wdl not be used this vear but Is intended for use to the future.Check this Box and return this application Fee Schedule 4J Permanent Camp Annual Permit Fee $50.00+ Number of Employees J 7 0 $15.00 each=$ I ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee S25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee S100.00+ Number of Emplovees $30.00 each=$ Fee must be submitted with Application TOTAL FEE DUE S Zj 1 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 Califorttia Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name ��S t/Y��" Title /--tIAk" Partnership (Please PRINT or TYPE) ❑Corporation 31_ApAddress Ls S 1310 -1— Phone 931- Applicant plicant Signature Date of Application 3�� I Ls Lo Amount Paid Date of Pay Payment Type Check/Receipt# Received By Account ID 1�y1�-J� Facility ID Program Record ID PIE Assigned to PWS ID N/A Report#:7066 Application Printed:3/3/2020