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San Joaquin County-Environmental Health Department <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 <br /> 41 UV <br /> APPLICATION SAN JO 2023 <br /> ENVIRONMENTAL HEALTH 'JOA CO <br /> UNrV <br /> PERMIT TO EMPLOYEE HOUSING OR LABOR CAMP TE yEALrN DEP Th7ENT <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <br /> []Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0011000 <br /> *Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000349 <br /> Site Name: RIVER OAK DAIRY 39-349 Location: 29770 E HWY 4,FARMINGTON <br /> Operator: KOOLHAAS,TOM <br /> Mailing Address: PO BOX 294, FARMINGTON CA 95230 Facility Phone#:(559)816-8075 <br /> Legal Owner: KOOLHAAS,TOM New Owner? ❑Yes ❑ No <br /> Owner Address: PO BOX 294, FARMINGTON CA 95230 Owner Phone#:(559)816-8075 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines 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 /> Im 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. <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$17.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ J <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed 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 <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name I ar— kp)4g4 g Title �,�✓n?� ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address Z977U �. ��sg�iv�.y Lf af/I,,n��Un �� 9S2�3G1 Phone– �2*(-P�.�// <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 13 5'.,b Z) zo 23 1`�22� 0002977 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0003400 PR0515646 2765 0039-GOODERHAM WA0515668 <br /> Report#:7066 Application Printed:11/1/2023 <br />