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RAYIWE�j.r <br /> .oaquin County-Environmental Health Depai <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 2t,7-468-3420 CE�VED <br /> M �a .. <br /> '�Q ^rte <br /> APPLICATION "^N JOAQtjENVIRONMENTAL HEALTH IN <br /> EMPLOYEE HOUSING ERMIT OR LABOR CAMP NEALT H DE 1 E-r N,,COUN� <br /> ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) >�nual Permit for Calendar Year 2.0;0' <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0027507 <br /> *Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: <br /> Site Name: BARRERA MALDONADO PROPERTIES LLC Location: 1108 ROSEMARIE LN,STOCKTON <br /> Operator: BARRERA, LUIS <br /> Mailing Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Facility Phone#:(831)272-3523 <br /> Legal Owner: BARRERA, EDGAR New Owner? ❑Yes ❑ No <br /> Owner Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Owner Phone#:(831)272-3523 <br /> Community Facilities Provided by Community Kitchen? ❑ Yes No <br /> Men: Number of Toilets 114 Number of Showers 4'A 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 /> Buildint=_s Emplovees <br /> Dormitories from o/0/aa' to Crop Cli' ,rc /> t Pep <br /> SF Dwellings from —/—/—to / / Crop <br /> Apartments �L 100 <br /> Owner Owned M14/RV Total Number of Days to be used this Calendar Year: 3c) <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS t� Camps occupied by 25 or more Employees for 60 or more days in a year <br /> �"1 too 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 /> f[� Permanent Camp Annual Permit Fee $50.00+ Number of Employees IL2 0 @$15.00 each=$ 1550 <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 vdth Application <br /> TOTAL FEE DUE$ <br /> Remit TOTAL FEE as CALCULATED ABOVE iit the ENCLOSED Self-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 Lute Bowr•et-h. Title MZ1 it,<j ell ❑Partnership <br /> (Please PRINT or TYPE) 1 <br /> ❑Corporation <br /> Address Ng-ro A.vertltg- dvs Alks �c�r �,, ; C� `�31v l Phone Ss31 o)–Q&1&2- <br /> Applicant <br /> &aApplicant Signature Date of Application 12•0 r-y� <br /> Amount Paid Date of 04ment Payment Type Check/Receipt# Received By Account ID <br /> �rU.�• I n �� ^ � � �r r, 0049219 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0025974 PR0545931 2755 9834-SUSZYCKI N/A <br /> Report#:7066 Application Printed:12/2/2021 <br />