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.a. <br /> e <br /> San Joaquin County-Environmental Health Department <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-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) Annual Permit for Calendar Year2725 <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 Vote any Corrections or Changes of hacihiylOperator Information directly on thisform. <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 Came: Community kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets l N Number of Showers 'A Number of Lavatories I N <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occunancv Dates: <br /> Buildings Emolovees /, <br /> Dormitories from 0Y I—PLlAOL to LZ 411 ! ZS Crop CW%"1 tS I()\ w's, <br /> SF Dwellings from _/ to_I_i Crop <br /> Apartments I Li 30 <br /> Owner Owned NIH!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 j O 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 /> r n Fee Schedule 110 Z Z�OZ 0d�g��= !ai$17.00 each=5 <br /> Pemtaneut Camp Annual Permit Fee Number of Employees <br /> ❑ Transfer of Ownership $25.00=S <br /> ❑ Permanent Amendment Fee S25.00- Number of Additional Employees iz1$17.00 each=S <br /> ❑ Late Application Fee S100.00— Number of Employees c$.34.00 each=S <br /> Fee must be submitted with Application <br /> TOTAL FEE DUES 2 r ZbZ. , <br /> —T <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adresscd 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 <br /> anal Safety Code and Chapter I,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name `/�/►S l ((,e Title ❑Partnership <br /> (Rease PRINT orTYPE) ❑Corporation <br /> Address In Lt p pNeriII;1& L(6 1 y t 1 gs skl Iry"s , l f enn I Phone �$��� � -3513 <br /> Applicant Signature Date of Application J2•4- �y <br /> Amount Paid Date of Payment Paym ype Check!Receipt t: Received By Account ID <br /> 0049219 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0025974 PR0545931 2755 9852-SALINAS NIA <br /> Report# 7066 Application Printed 1 0/2 812 02 4 <br />