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San Joaquin County-Environmental Health Department <br /> 1868 E Ilazelton.Ave-Stockton CA 95205-Phone: 209468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL IIEALTII <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Nfultiple fears(Permanent Housing Camps only) ® Annual Permit for Calendar Year 2026 <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 thisforrn. <br /> Site Name: RIPON FARMS 39430 Location: 23531 S JACK TONE RD RIPON <br /> Operator: RIPON FARMS39-430 Email: <br /> Mailing Address: 1532 SCENIC DR,MODESTO CA 95355 Facility Phone#: (209)492-9335 <br /> Legal Owner: HOGAN,THOMAS P New Owner? ❑ Yes ❑ No <br /> Owner Address: 1532 SCENIC DR,MODESTO CA 95355 Owner Phone#: (209)604-5280 Email: <br /> Community Facilities Provided by Camp: Community Kitchen'? ❑ Yes ❑ No <br /> Men: NumberofToilets Number of Showers Number of lavatories <br /> Women: NumberofToilets Number of Showers Number of Lavatories <br /> Ilousine Accommodations to be Utilized this Year: Occunancy 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 /> O«ner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MII/RV Spaces <br /> 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 <br /> ❑ Permanent Camp Annual Permit Fee $54.00+ NumberofEmployees @$17.00 each=$ <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 <br /> TOTAL FEE DUES <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 /> Safet},Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name Title ❑Partnership <br /> (Pleaso PRINT or TYPE) ❑Corporation <br /> Address Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> 17AO020793 PRO536203 2765 Rena LeRoy <br /> Report#:7067.rpt <br />