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San Joaquin County - Environmental Health Department <br />1868 E Hazelton Ave - Stockton CA 95205 - Phone: 209468-3420 <br />APPLICATION <br />ENVIRONMENTAL HEALTH <br />PERMIT TO OPERATE <br />EMPLOYEE HOUSING OR LABOR CAMP <br />❑ New Camp ❑ Conditional Permit ❑ Multiple Years (Permanent Housing Camps only) ® Annual Permit for Calendar Near 2027 <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 - <br />STOCKTON INN <br />Location: 4219 E WATERLOO RD STOCKTON <br />Operator: EMPIRE FARM LABOR CONTRACTOR LLC - STOCKTON <br />INN <br />Email: <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 ❑ No <br />Owner Address: 17450 AVENIDA LOS ALTOS, SALINAS CA 93907 <br />Owner Phone #: (831)272-3523 Email: <br />Community Facilities Provided by Cama: Community Kitchen? ❑ Yes ❑ No <br />Men: NumberofToilets NumberofShowers <br />Women: Number of Toilets NumberofShowers <br />Housing Accommodations to be Utilized this Year: Occupa ucv Dates: <br />Buildings Employees <br />Dormitories <br />SF Dwellings <br />Apartments <br />Owner Owned MH / RV <br />Owner Owned RR Cars <br />MH / RV Spaces <br />TOTALS <br />Number of Lavatories <br />Number of Lavatories <br />from / / to / / Crop <br />from / / to / / Crop <br />Total Number of Days to be used this Calendar Year: <br />Total Days Occupied by 25 or more Employees: <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 />Im portant: 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 />❑ Permanent Camp Annual Permit Fee $54.00+ Number of Employees @ $17.00 each = $ <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 DUE $ <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 />Safety Code and Chapter 1, Subchapter 3, Title 25, California Code of Regulations. <br />Applicant Name Title ❑ Partnership <br />(Please PRINT or TYPE) ❑ Corporation <br />Address Phone <br />Applicant Signature <br />Date of Application <br />11 Amount Paid I Date of Payment I Payment Type I Check/Receipt # I Received By I <br />Facility ID I Program Record ID I PIE I Assigned to I PWS ID II <br />P.AO027596 IPRO548338 12765 ISastina Thammavongsa <br />Report #. 7067.rpt <br />