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San Joaquin County-Environmental Health Department PAYMENT 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 RECEIVED APPLICATION DEC 2 2 2022 ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#• 0011000 *Additional Employees State ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000349 Site Name: RIVER OAK DAIRY 39-349 Location: 29770 E HWY 4, FARMINGTON Operator: KOOLHAAS,TOM Mailing Address: PO BOX 294, FARMINGTON CA 95230 Facility Phone#:(559)816-8075 Legal Owner: KOOLHAAS,TOM New Owner? ❑Yes ❑ No Owner Address: PO BOX 294, FARMINGTON CA 95230 Owner Phone#:(559)816-8075 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildines Employees Dormitories from _/_/ to_/ / Crop 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 1 nt portant: 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 r Y Permanent Camp Annual Permit Fee $50.00+ Number of Employees _ @$17.00 each=$ ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$34.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ � 3 j-- Remit 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 Title ❑ Partnership (Please PRINT or TYPE) ❑Corporation Address Phone Applicant Signature Date of Application Amount Paid �� Date of Payment Payment Type Check//Receipt# Received By Account ID /3 c-. 2_2123 D_/z 0002977 Facility ID Program Record ID P/E Assigned to PWS ID FA0003400 PR0515646 2765 0039-GOODERHAM WA0515668 Report#:7066 Application Printed:11/28/2022