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PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 APR 13 2023 <br /> ENVIRO COUNTY <br /> APPLICATION HEALTH DEPAENTAL <br /> ENVIRONMENTAL HEALTH R TM EN T <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> d New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year ap�) <br /> ❑Amended Permit: *Change of Operator 'Change of Owner <br /> *Change of Operator Address 'Change of Owner Address Permit ID#: 0029152 <br /> 'Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operatorinformation directly on this form. EH ID#• <br /> Site Name: EMPIRE FARM LABOR CONTRACTOR LLC-STOCKTON INN Location: 4219 E WATERLOO RD,STOCKTON <br /> Operator: BARRERA,LUIS <br /> Mailing Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Facility Phone#:(209)931-3131 <br /> Legal Owner: EMPIRE FARM LABOR CONTRACTOR LLC 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 1 I Number of Showers y Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees <br /> Do ' s gyRMS 17Y from OT C" /-)-3 to 12/9l/23 Crop <br /> SF Dwellings from _/_/ to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 7�J <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces <br /> Note <br /> TOTALS © 1 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 GG Uo <br /> Permanent Camp Annual Permit Fee $50.00+ Number of Employees 11 LA @$17.00 each=$ i 0 D <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 1 00 <br /> TOTAL FEE DUES � 3 1 0�� ' <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 (//,S r e r—� Title Gt►t GcE/� ❑Partnership <br /> (Please PRINT or TYPE El Corporation <br /> Address Phone g 3 -211 3 5 23 <br /> Applicant Signature Date of Application V A/ I .9- <br /> 2 Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 3� �d0e 0(0 4 1z 2� i✓ /%��l Jg�l 0053402 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0027596 PRO548338 2765 3611-GIRARDI N/A <br /> Report#:7068 <br /> Application Printed:3/23/2023 <br />