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PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> DEC 3 0 2o2 <br /> APPLICATION "AN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP 10 <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#• 0027507 <br /> *Additional Employees <br /> State ID#: <br /> EH ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: BARRERA MALDONADO PROPERTIES LLC Location: 1108 ROSE MARIE LN,STOCKTON <br /> Operator: BARRERA,LUIS <br /> Mailing Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Facility Phone#:(831)272-3523 <br /> Legal Owner: BARRERA,EDGAR New Owner? ❑Yes ❑ No <br /> Owner Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Owner Phone#:(831)272-3523 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets N Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> liousing Accommodations to be Utilized this Year: OccupancN Dates: <br /> Buildines Employees <br /> Dormitories from ON /01/ 7�j to M/21 / ZS Crop Ckw"o I( t QPPu3 <br /> SF Dwellings from_/_/ to_/ / Crop <br /> Apartments 14 130 <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 /> 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 /> VP.anent Camp Annual Permit Fee Number ofEmployees 13p @$17.00 each=$ Z t Z wZ 00 <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$ Z t 2b2 . 0� <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 Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name �/V IS ��( {(e (-6\- Title mw/ ❑Partnership <br /> (Please PRINT or TYPE) I ❑Corporation <br /> Address 1'l450 Ageo► L(6 Al�R ad S I naS , �A !.S o Phone (61�, 2,371 -3S? 3 <br /> Applicant Signature �_�-� Date or Application 02•2 a <br /> Amount Paid Date of Payment Paym ype Check/Receipt# Received By Account ID <br /> 2ocp 00492,9 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0025974 PR0545931 2755 9852-SALINAS N/A <br /> Report#:7066 Application Printed:10/28/2024 <br />