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San Joaquin County-Environmental Health Department <br /> 600 E.Main Street-Stockton CA 95202-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) t Annual Pcrmll for Calends,Ycar <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> `Change of Operator Address *Charge of Owner Address Permit IDN: <br /> -Additional Employees <br /> State ID N: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on This form. EH ID N: <br /> Site Name: BhYli>° Iq� S -410 Location: l� hd6" C <br /> Operator: r Le p 0 1 <br /> \lailiog Address: ?j�� , �• t' (j� � �a C✓1 Facility Phone q: <br /> ao <br /> Legal Owner: O yl I1 l'( (CAV% 's 1`c . New Owner' ❑cYes <br /> g1No <br /> Owner Address: vet 1 223 vl rtM S {s vt S �wner Phone a: <br /> Community Facilities Provided by Camp: Community Kitchen 7 Ye ❑ No <br /> Nita: Number of Toilets r 3 Number of Showers _ Number of Lavatorics <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> j_lousine Accommodations to be Utilized this Year: Occupancy Datca: <br /> Buildines Em lovees <br /> Dormitories from a /�S/ a 1 to rs a i Crop <br /> SF Dwellings from _ _l�/ to!/_/ Crop <br /> Apanmcnls TT D <br /> Owner Owned MH/RV -T Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: O <br /> hiH/RV Spaces Nim <br /> -�^ Camps occupied by 25 or more Employees for 60 or more days in a year <br /> TOTALS J L-- ---^^-' 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 rcrum this application. <br /> Fce Schedule <br /> _ <br /> W Permanent Camp Annual Permit Fee S35.00+ Number of Employees G S 12.00 each=S <br /> !l1---111 ❑ Orchard Camp Permit Fee $95.00-5 <br /> Transfer of Ownership 520.00=S <br /> Permanent Amendment Fee $20.00+ Numbcr of Additional Employces Q$12.00 each=S <br /> 570.00+ Nutnbor of Employees (u7 S24.00 each=S <br /> ❑ Late Application Fee O <br /> Fee must be submitted with Application TOTAL FEE DUES l U <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE toEHD <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 Safery Code and Chapter 1,Subchapter 3,Title 25,California Cod�lelo�jRegalations. �Q J� ,n �1��I IA^ ❑partnership <br /> Applicant Name VV�t 4"( G�� �{^ �/U Ii�C Title '1(� <br /> p ❑Corporation <br /> (Please PRINT or TYPE) r' l 1 / ` /4) <br /> Address a <br /> 0��� l: � �1 6�'� �� �'1^ cM Phone 1pr�� (P�P'I�10-r <br /> � Date of Application <br /> Applicant Signature <br /> Amount Paid Date of Paym nt PaymAccount ID <br /> ent Typo Check/Racelpt0 Received By <br /> Facility ID Program Record ID PIE <br /> Assigned to PWS ID <br /> Application Pnnted:111212021 <br /> Reowl it:7067.rpt <br />