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San Joaquin County-Environmental Health Department <br /> 1868 E Hazelton Ave-Stockton CA 95205-Phone: 209468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit for Calendar Year 2027 <br /> ❑ Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: River Oak Dairy Location: 29770 E HWY 4 FARMINGTON <br /> Operator: River Oak Dairy Email: <br /> Mailing Address: PO BOX 294,FARMINGTON CA 95230 Facility Phone#: (559)816-8075 <br /> Legal Owner: PO BOX 294,FARMINGTON CA 95230 New Owner? ❑ Yes ❑ No <br /> Owner Address: PO BOX 294,FARMINGTON CA 95230 Owner Phone M (559)816-8075 Entail: <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: NumberofToilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from / / to / / Crop <br /> SF Dwellings from / / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces 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: 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 /�C <br /> Permanent Camp Annual Permit Fee $54.00+ Number of Employees `0 @$17.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $108.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application �y <br /> TOTAL FEE DUE S 5I <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed 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 and <br /> Safety Code and Chapter 1,Subc apter 3,Title 25,California Code of Regulations. <br /> Applicant Name 10.^1 A."op14tzas Title G"VA el— ❑Partnership <br /> (Please PRINTor TYPE) /% Q y /,L� ❑Corporation <br /> Address Pp �hf �C I Felt#" llol'��/1 . (1r I �S 2 �O Phone ?�°?-3 12`l1 <br /> I <br /> Applicant Signature f- j�� Date of Application 71Z C <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By <br /> � 2u ' U2-1 C/ <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0003400 PR0515646 765 Sastina Thantmavongsa <br /> Report#.7067.rpt <br />