Laserfiche WebLink
` San Joaquin County-Environmental Health Department <br /> 1868 E Hazelton Ave-Stockton CA 95205-Phone: 209-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP 1 <br /> E]NewCamp E]ConditionalPermit ❑ 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: EMPIRE FARM LABOR CONTRACTOR LLC- Location: 4219 E WATERLOO RD STOCKTON <br /> STOCKTON INN <br /> Operator: EMPIRE FARM LABOR CONTRACTOR LLC-STOCKTON Email: o ` �� <br /> INN <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 [VNo p, <br /> Owner Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Owner Phone#: (831)272-3523 Email: rv- 'of I <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: NumberofToilets 5u Number of Showers 50 Number of Lavatories FSy <br /> Women: Number of Toilets e5o Number of Showers V Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories OO from OI /01 /24o to 1'L /31 /2(o Crop Q-jrrieJ0 PeeP CSI <br /> SF Dwellings from / / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: '3 los <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 'a <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 be used this year but is intended for use in the future,Check thus Box and return this application. <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fee $54.00+ Number of Employees 2.00 @$17.00 each=$ 3 f 4 S'1,0 O <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 DUES ._4 S Li <br /> RemitTOTAL 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 /> Safely Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name Lu 1 g govrr� Title ❑Partnership <br /> (Please PRINTorTYPE) ❑Corporation <br /> Address 6115-6 tWto ""S Saj, -13-1d-: Phone (040 1-11--3S23 <br /> Applicant Signatu re Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By <br /> F cilityID P ogram Record ID PIE Assigned to PWS ID <br /> FA0027596 PRU�-IS33S '761 YMEN SastinaThanuua%ongsa <br /> Report#:7067.rpt <br /> JAN 1 2 2* <br /> 1 NV RON"V IAt �' <br /> i AI IVI ni PARI•tl t: <br />