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__.Joaquin County-Environmental Health Departme- <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 REC D���,f y N•7. <br /> E 11 <br /> APPLICATION FEB Q 3 X021 <br /> ENVIRONMENTAL IIEALTII <br /> PERMIT TO OPERATE Sq N J <br /> EMPLOYEE HOUSING OR LABOR CAMP (F QE/N7�uRN N COIN -Y <br /> ❑New Camp ❑Conditional Permit Multiple Years(Permanent housing Camps only) ❑Annual Per." for C41lAda ON1 NT4 <br /> [:]Amended Permit: 'Change of Operator *Change of Owner R <br /> "Change of Operator Address *Change of Owner Address Permit ID#: 0027815 <br /> *Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on thisform. EH ID#: <br /> Site Name: BONNIE PLANTS Location: 23975 E MILTON RD,LINDEN <br /> Operator: DE LAMADRID,MIGUEL <br /> Mailing Address: 23975 E MILTON RD,LINDEN CA 95236 Facility Phone#:(619)664-6921 <br /> Legal Owner: DE LA MADRID,MIGUEL New Owner? ❑Yes ❑ No <br /> Owner Address: 23975 E MILTON RD,LINDEN CA 95236 Owner Phone#:(619)664-6921 <br /> Community Facilities Provided by Campy 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 /> IlousinL,Accommodations to be Utilized this Year: Occupancy Dates: <br /> Building$, Employees <br /> Dormitories �_ from /_I 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: I�O <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> M-I/RV Spaces NDk <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 II (J D= <br /> Permanent Camp Annual Permit Fee S50.00+ Number of Employees 1 @$15.00 each=$ t u <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ <br /> Fee must be submitted with Application 2l 0 ,u, <br /> TOTAL FEE DUE$ l <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EIID <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 1IOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health <br /> and Safery Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. n <br /> Applicant Name M16,1! ( <br /> l d 2 It, W\&Jr t A Title ley I OY`(.L MVt(.Al�✓ Partnership <br /> Corporation(Please PRINT orTYPE) t 6t-o, ❑Corpo/ration <br /> Address 23��5 �. �, �b Ltr��Qv� C� �Sa3� Phone <br /> Applicant Signature Date of Application 13 -1,.7L� <br /> Amount Paid Date of Paym nt Payment Type Check/Receipt# Received By Account ID <br /> 2qf) DL) dt 3 � V I S l 0050073 <br /> V 11°f l95 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0026344 PRO546475 2765 '8987-SANGALANG N/A <br /> 12U��7� <br /> Report JY 7066 Application Printed:2/3/2021 <br />