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San Joaquin County-Environmental Health Department <br /> 1868 E Hazelton Ave-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 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 this form. <br /> Site Name: BARRERA MALDONADO PROPERTIES LLC Location: 1108 ROSE MARIE LN STOCKTON <br /> Operator: BARRERA MALDONADO PROPERTIES LLC Email: <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 Email: CoM <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets 'N Number of Showers t 4 Number of Lavatories 1`4 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housima Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildin¢s Employees <br /> Dormitories from UM /01 / 24v to IZ/ 11 / Z& Crop C4,ar.H _VK. t Pei-fTS <br /> SF Dwellings from / / to / / Crop <br /> Apartments L V <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 2'1 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: Z 1 s <br /> MH/RV Spaces Note <br /> TOTALS �� ,3l� 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+ Number of Employees 130 @$17.00 each=$ 21 Z-V 2 66 <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 DUE$ Z 1 -O 0 <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 /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name L(l jS P-'e'rl-mil. Title pytw, � partnership <br /> (Please PRINT or TYPE) ' ❑Corporation <br /> Address 1`4S-U Prig v'i tits 'hS aUna (;A 91,101" Phone (ft)211-3S"Z3 <br /> Applicant Signature �~ Date of Application Z•(9 25 <br /> Amount Paid Date of Payment ')Payment Type Check/Receipt# Received By <br /> a(f L�— \ I X25 A Lio 5 1(10 S Clk- <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0025974 PIZO545931 755 Sastina Thanunavongsa <br /> Report#:7067.rpt RECEIVE D <br /> JAN 2 3 2026 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />