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PgYV <br /> RECEIVED San Joaquin County-Environmental Health Department ! T <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 I V C D <br /> MAR 1 0 2024 MAR 19 =4 <br /> ENVIRONMENTAL HEALTH APPLICATION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH ENVIRONMENTAL <br /> DEPARTMENT PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp []Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) EAnnual 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 /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH H)#• <br /> Site Name: SMITH PACKING-WATERLOO FACILITY Location: 4219 E WATERLOO RD, STOCKTON <br /> Operator: HERNANDEZ, EMANUEL <br /> Mailing Address: 312 E MILL STE 202,SANTA MARIA CA 93454 Facility Phone#:(805)249-7171 <br /> Legal Owner: SMITH,VERNON New Owner? ❑Yes ❑ 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 �1 Number of Showers 1 Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from A__/_E_/_2A_to / / Crop Y e <br /> SF Dwellings from / / to_/ / Crop <br /> Apartments <br /> Owner Owned ME/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 /> ME/RV Spaces to <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 /> d Permanent Camp Annual Permit Fee $50.00+ Number of Employees 12)ip @$17.00 each=$ je-I L <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$ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-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 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 � '� Title ORII.40%k Sr ❑Partnership <br /> (Please PRINT or TYPE) It i ^h 1- w ❑Corporation <br /> Address �\2 �, �\ ��- til)Z %1[�_n*P,4Y1CA Phone e(pzj <br /> Applicant Signature Date of Application '3I,1 9-02d. <br /> Amount Paid Date of Payment Payment Type heck eceipt# Received By Account ID <br /> r1 �� l � 0051048 LI 724 <br /> Ila- W2�6 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0026784 PR0547200 2765 0034-AHMED IN/A <br /> Report#:7066 Application Printed:11/1/2023 <br />