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PAYMENT ' R E C E I V 1 San Joaquin County-Environmental Health Department 1 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 RECEIVED MAR 3 1 2023 SAN JOAQUIN COUNTY APPLICATION MAR 3 1 202.E ENVIRONMENTAL ENVIRONMENTAL HEALTH HEALTH DEPARTMENT PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP LNN IRON.NIFN I.�L IIL.kLl'll ❑ New Camp ❑Conditional Permit ❑ Multiple Vears(Permanent(lousing Camps only) Pg Annual Permit for CalAWY)NO OMN I ❑ Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#: 0022183 *Additional Employees State ID#: 39-15855-EH EH ID#: 39000430 Please Note any Corrections or Changes in Facility/Operator Information directivon th/sform. Site Name: RIPON FARMS 39-430 Location: 23531 S JACK TONE RD, RIPON Operator: HOGAN,THOMAS P Mailing Address: 1532 SCENIC DR, MODESTO CA 95355 Facility Phone#:(209)492-9335 Legal Owner: HOGAN,THOMAS P New Owner? ❑Yes No Owner Address: 1532 SCENIC DR, MODESTO CA 95355 Owner Phone#:(209)604-5280 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes in No Men: Number of Toilets n/a Number of Showers n/a Number of Lavatories n/a Women: Number of Toilets n/a Number of Showers n/a Number of Lavatories n/a Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildint=_s Emplovees Dormitories from 1 / 1 /202:?b 12/31/ 2023 Crop Varies SF Dwellings from _/_/ to / / Crop Apartments �- Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 365 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 0 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 Important: In order to protect your land use status,ifcamp will not be used this year but is intended for use in the future,Check this Box and return this application. Fee Schedule ® Permanent Camp Annual Permit Fee $50.00+ Number of Employees 8 av$17.00 each=$ 136 . 00 ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees a $17.00 each=$ Late Application Fee $100.00+ Number of Employees a $34 00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 18 6 • 0 0 Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to MID 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 ROUSING .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 Thomas Hogan Title Owner ❑ Partnership (Please PRINT or TYPE) ❑Corporation Address 1207 13th STJE 1 , Modesto CA 95354 Phone (209) 492-9335 Applicant Signature Date of Application 2/15/2 0 2 3 Amount Paid Date of Payment Payment Type C eckt ceipt# Received By Account ID 4 �•, 3 3 1 23 �71 H 0037333 Facility ID Program Record ID P/E Assigned to PWS ID FA0020798 PR0536203 2765 0039-GOODERHAM N/A Report#:7066 Application Printed:11/28/2022