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` San Joaquin County - Environmental Health Department <br />1868 E Hazelton Ave - Stockton CA 95205 - Phone: 209-468-3420 <br />❑ New Camp ❑ Conditional Permit <br />❑ Amended Permit: *Changeof0perator <br />*Change of Operator Address <br />*Additional Employees <br />APPLICATION <br />ENVIRONMENTAL HEALTH <br />PERMIT TO OPERATE <br />EMPLOYEE HOUSING OR LABOR CAMP <br />❑ Multiple Years (Permanent Housing Camps only) ® Annual Permit for Calendar Year 2026 <br />*Change of Owner <br />*Change of Owner Address <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 - <br />STOCKTON INN <br />Location: 4219 E WATERLOO RD STOCKTON <br />Operator: EMPIRE FARM LABOR CONTRACTOR LLC - STOCKTON <br />IMV <br />Email: o` �� <br />Mailing Address: 17450 AVENIDA LOS ALTOS, SALINAS CA 93907 <br />Facility Phone #: (209)931-3131 <br />Legal Owner: EMPIRE FARM LABOR CONTRACTOR LLC <br />New Owner? ❑ Yes [VNo <br />Owner Address: 17450 AVENIDA LOS ALTOS, SALINAS CA 93907 <br />p, <br />Owner Phone #: (831)272.3523 Email: r-' ' 0- t <br />Community Facilities Provided by Camp: Community Kitchen ? ❑ Yes ❑ No <br />Men: NumberofToilets 5u Number of Showers so Number of Lavatories FSO <br />Women: Number of Toilets 0 Number of Showers V Number of Lavatories 50 <br />Housine Accommodations to be Utilized this Year: <br />Buildings Employees <br />Dormitories 7-00 <br />SF Dwellings <br />Apartments <br />Owner Owned MH / RV <br />Owner Owned RR Cars <br />MH / RV Spaces <br />TOTALS j <br />Occupancy Dates: <br />from OI /Ul /7-1.p to 1'1 131 1'2(o Crop Gho r r iej Pee P CS <br />from / / to / / Crop <br />Total Number of Days to be used this Calendar Year: '3 los <br />Total Days Occupied by 25 or more Employees: 'a <br />Note <br />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 />Imuortant: 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 flus 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 ofAdditional 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 S :3_ 4 S Li <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 />Safely Code and Chapter 1, Subchapter 3, Title 25, California Code of Regulations. <br />Applicant Name Lu 1 g gpv�r� Title yy❑ Partnership <br />(Please PRINTorTYPE) ❑ Corporation <br />Address 61L15-6 tWto-.J-- LpS ""S Staj, Phone (0401-11--3S 23 <br />Applicant Signatu re > Date of Application <br />Amount Paid <br />Date of Payment Payment Type Check/Receipt # <br />Received By <br />4M-2,1 <br />F cilityID <br />ram Record ID PIE Assigned to <br />PWS ID <br />FA0027596 <br />PRo,4S33S 71,E PAYMENT SastinaThanuua%on,,sa <br />Report #: 7067.rpt <br />JAN 1 2 2* <br />1 NV RON"V IAt �' <br />�i� <br />At 111 ni PARI�•�I N, <br />