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San Joaquin County-Environmental Health Department <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 204-468m-3420 <br /> APPLICATIOM <br /> EN V IRONY ENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOI JEW OR LABOR CAMP <br /> CS�Ntw Camp ❑Conditional Permit ❑ Multiple Years(Permanent Horsing Camps oaly) J9 Annual Permit for Calendar Year 2 ZZ <br /> ❑Amended Permit `Change of Operator *Change of 0.0- <br /> *Change of Operator Address 'Change of Owner Address Permit ED#: 0028888 <br /> •Addtnoaal Employees <br /> State 1D#: <br /> Please Note any Corrections or Changes in FaciJig/Operator information directly on riusform. EH H)#• <br /> Site Name: STERLING FARMS LLC Location: 22220 N HWY 99,ACAMPO <br /> Operator: BURNETi,TODD <br /> Mailing Address: 17250 E KETTLEMAN LN,LODI CA 95240 Facility Phone#:(209)401.5177 <br /> Legal Owner: BURNETT,TODD New Owner' ❑Yes ❑ No <br /> Owner Address: 17250 E KETTLEMAN LN,LODI CA 95240 Owner Phone#:(209)401-5177 <br /> Community Facilities Provided by Camp: Community Kitchen 7 JR Yes ❑ No b <br /> Men: NumberofToiletu NumberofShowers Z� r ��T Ntmlberoff-avatories <br /> Women: Number of Toilets NumberofShowets Numbcrofl.avatories <br /> Housing Mcommodations to be Utilized this Ycan.. Occupancy Dates: <br /> BuildingsEmployees fro, � e- <br /> Dormitories .tt[�-/ i /��to�2l�/ 2-1— trop YeSneg R <br /> SFDweliings - from if/_.1-3 to 12-/ 3�1_ZCrop <br /> Apartments <br /> Owner Owned MIH/RV Total Number of Days to be used this Calendar Year: 4 6 S- <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees. --- } <br /> MH/RV Spaces <br /> Note <br /> TOTALS ® © Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> Important:Tn order to protect your land ore status,if camp will not be used this year but is intended for use in the iunue,Check this Bnx and return this application <br /> Fee Schedule <br /> Permanent Camp Annual Permit Foc S50.D0+ Number of Employees S a@$17.00 each=S V 0'0 <br /> ❑ Transfer of ownership $25.00-5 <br /> ❑ Permanent Amendment Fee 525.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees Q$34.00 each-S <br /> Fee most be submitted with Application <br /> TOTAL FEE DUE 5 <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressedd Envelope <br /> MAKE CHECKS PAYABLE to EHD 4 L ftL 43)y QA <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 malutalned in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT, Chapter 1, Part 1, Division 13 of, pa California XeaUB <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code ofReguladom. 1=-tp 4.4f it-b P AOtLrry , . <br /> Applicant Name ' rO b.A �C/PgJ r l Title el W/J� 9Al4-T/U-G-f— 11Parmcrsbip G7MP,MIJ'S/ <br /> (PI-m PRINT or TYPE) / ❑corporation <br /> Address 17 7-Sr1 E LAl y�Z Phort ?'o S), 4 O/ <br /> Applicant Signature Date of Application /ah IZZ <br /> Amount Pald Date of Payment Payment Type C Roeolpt# ReceNed By Account ID <br /> b7ti Jb --/J /` 00$2710 <br /> Facility ID C/ `Program Record ID (I,�FIE /J Assigned to PWS ID <br /> FA0027372 PRO547994 2765 8987-SANGALANG N/A <br /> EReport#:7088 Application Printed:10/52021 <br />