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f�P San Joaquin County-Environmental Health Department a\ c�te'�� 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 e/V�D Orr a n APPLICATION SAN JO ENVIRONMENTAL ERMIT TO OPERATE HEALTH MEA rH EPgR Ttv q �' EMPLOYEE HOUSING OR LABOR CAMP TM ❑New Camp ❑Conditional Permit Multiple Years(Permanent Housing Camps only) ©'Annual Permit for Calendar Year Zr' ❑Amended Permit: *Change of Operator *Change of Owner "Change of Operator Address "Change of Owner Address Permit ID#• 0027507 "Additional Employees State ID#: EH ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on this form. Site Name: BARRERA MALDONADO PROPERTIES LLC Location: 1108 ROSEMARIE LN,STOCKTON Operator: BARRERA,LUIS Mailing Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Facility Phone#:(831)272-3523 Legal Owner: BARRERA,EDGAR New Owner? ❑Yes ❑ No Owner Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Owner Phone#:(831)272-3523 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ET No �f Men: Number of Toilets ' Number of Showers / / Number of Lavatories l Women: Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildines Employees / 130/1l to/?l 3l l Z I Crop Pt PIS 0 Vt+� Dormitories � from P �Q✓✓1 f�� SF Dwellings from _/_/ to_/ / Crop Apartments vU Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3 35 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 3 35 MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year X00 Require a PUBLIC WATER SYSTEM Permit ❑Inacti% I in po rtant: 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 Permanent Camp Annual Permit Fee $50.00+ Number of Employees /00 @$15.00 each=$ 1, J C 6 0 ❑ 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 must be submitted with Application TOTAL FEE DUF 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 I,f �Q ryt,,t Title as 44[ ►� ❑Partnership (Please PRINT or TYPE) Aven A —' El Corporation Address �L/ 0"AI?l C•L� S p`s',�f NAS � � Phone ( �dr/--1—OCR 0, Applicant Signature _ Date of Application 1 Z N Zoz C `Amount Paid Date of Payment /�/P/ayyment Type Check/Receipt# Received By Account ID /J S�D b� 1� 3 2 L/ I S f %� 0049219 Facility ID Program Record ID P/E ! Assigned to PPJS ID FA0025974 PR0545931 2755 8987-SANGALANG N/A Report#.7066 Application Printed:11/19/2020