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San Joaquin County-Environmental Health Department 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209.468-3420 APPLICATION ENVIRONAU-_ AL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP �ErNcw Camp ❑Conditional Permit ❑ Nutttple Years(Permanent Housing Camps only) Annual Permit for Calendar Year 2 O 2Z. ❑Amended permit: 'Change of Operator "Change of Owner 'Change of Operator Address 'Change of Owner Address Permit ID#: 002$$$$ 'Additional Employees State ID#: Please Note an Corrections or Chan EH ID#: y Changes in Facilfl}/Operatorinjormation directly rhisjorm. Site Name-. STERLING FARMS LLC Location: 22220 N HWY 99,ACAMPO Operator: BURNETT,TODD MafHng Address: 17250 E KETTLEMAN LN,LODI CA 95240 Facility Pbone#:(209)401-5177 Legal Owner: BURNETT,TODD New Owner? ❑Yes ❑ No Owner Address: 17250 E KETTLEMAN LN,LODI CA 95240 Owner Phone#:(209)401-5177 Community Fadlfdes Provided by Camp; Community Kitchen? Yes ❑ No Alen: NtrmbaofToilelt: .3 NumberofSbowem �-� J84T Number ofLavatories Women: NtmlberofToilctc NumberofShowers Number of Lavatories Housine Accommodations to be Utilized this Year Occupancy Dates: Bulldin¢s Employees Dormitories from L?n/ / ZZ to jZl 1 LZZ tip L4 V 57Z `( A4 SF Dwellings - - fmm !OJ- 1/.2-3 to >z/ 311 3 Crop Apartmepts Owner Owned MR/RV Total Number of Nays to be used this Calendar Year: -3 Owns Owned RR Cars Total Days Occupied by 25 or more Employs es: MH/RV Spaces � --� Note TOTALS I I Camps occupied by 25 or more Employees for 60 or more days is a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive Important:border to protect your land nse.�tmrs,ifcamp will not be used this year but is intended for use in the fnhac,Cheek this Sox and return This applirntioa Fee Schedule -Q<> 57 Pemtaaear Camp Annual Permit Fx S50.DO+ Number of Employees Qa S 17,00 each=S v�' ❑ Transfer of Ownership $25.00-S ❑ Permanent Amendment Fee S25.00+ Number of Additional Employees Q S 17.00 each=S ❑ Late Application Fce S 100.00+ Number of Employees Q S34.00 each-$ Fee must be submitted with.Application �^ TOTAL FEE DUES �3�•C O Remit TOTAL FEE as CALCULATED ABOVE In the ENCLOSED Self-adresseedd Envelope pee*1 MAKE CHECKS PAYABLE to ERA L 9 PA i 1J I O 7 27 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 t, Division 13 of the California Heolrh and Safety Cade and Chapter I,Subchapter 3,Title 25,California Code ofRegaladons. 4/4r7rlb Lj a�(UTjr Applicant Name --(vD.A -6Ur2V11>�TT Title t)wN�1 PAP—TAJ� ❑Partnership C-��Tp' (PI.—PRiN7 or TYPE) � ❑CorpOratiOa Address 7ZSi1 E. r7 1-CM Ll�Y1r1C Lp11 �fSZ Phonr��i�1�0/�S^!� Applicant Signature — Date of Application Amount Pald Data of Payment Payment Typo C Racelpt tR RocuN¢d By Account 10 I 60 l ZZ /f/J c�-7� 0052710 Facility M Program Record ID PIE Assigned to PWS ID FA0027372 PR0547994 2765 8987-SANGALANG NIA Report#:7066 Application Printed:10152022