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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 /> APR 0 3 2023 <br /> APPLICATION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH ENVIRONMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) dAnnual Permit for Calendar Year <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0028271 <br /> *Additional Employees <br /> State ID#: <br /> EH ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Inforination directly o»this firm. <br /> Site Name: SMITH PACKING-WATERLOO FACILITY Location: 4219 E WATERLOO RD,STOCKTON <br /> Operator: L N <br /> YA�" S"A-\ <br /> Mailing Address: 312 E MILL STE 202,SANTA MARIA CA 93454 Facility Phone#:(8057249-7171— <br /> Legal Owner: SMITH,VERNON New Owner? ❑Yes Ejf/No <br /> Owner Address: 312 E MILL STE 202,SANTA MARIA CA 93454 Owner Phone#:(805)357-1322 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes No <br /> Men: Number of Toilets Number of Showers 9 Number of Lavatories C <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees l C <br /> Dormitories from J/ �!/ to d' l l 3 Crop -r---e T u 1 <br /> SF Dwellings from_/ / to _/ Crop <br /> Apartments <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 he 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 $50.00+ Number of Employees @$17.00 each=$ Co la <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 r - _ <br /> TOTAL FEE DUE$ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Selt adressed 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 I, Division 13 of the California Health <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name ��/ �� S(`(l� Title Iy&&t--oy- ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address 3ta a(� Sa 6 � Phon(305) 35—1-133o' <br /> Applicant Signature �!r/o2r '�A.-��ir v� Date of Application <br /> G Amount Paid Date of Payment Payment ype Check/ ceipt# Received By Account ID <br /> `1t a: ?5 L-,,3 n2, y i 0051048 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0026784 PR0547200 2765 9834-SUSZYCKI N/A <br /> Reoort#:7066 /Application Printed:3/29/2023 <br />