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PAYMENT • San Joaquin County-Environmental Health Department RECEIVED 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 FEB 2 6 2024 SAN JOAQUIN COUNTY APPLICATION ENVIRONMENTAL ENVIRONMENTAL HEALTH HEALTH DEPARTMENT PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ^n ❑New Camp El Conditional Permit ❑ Multiple Years(Permanent housing Camps only) Annual Permit for Calendar Year ud'�'A ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#: 0029152 *Additional Employees State ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: Site Name: EMPIRE FARM LABOR CONTRACTOR LLC-STOCKTON IN Location: 4219 E WATERLOO RD, STOCKTON Operator: BARRER& LUIS Mailing Address: 17450 AVENIDA LOS ALTOS, SALINAS CA 93907 Facility Phone#:(209)931-3131 Legal Owner: EMPIRE FARM LABOR CONTRACTOR LLC New Owner? ❑Yes ❑ No Owner Address: 17450 A\tENIDA LOS ALFOS, SALINAS CA 93907 Owner Phone#:(831)272-3523 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes P6 No Men: Number of Toilets S O Number of Showers S Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildines Employees Dormitories Aso 1;v 0 from M /01/,V W to 12L /31 `eZQa-N Crop CVV O "I thv'N'S t Pt Jftn SF Dwellings from _/_/ to_/_/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Note TOTALS ® Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive 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. Fee Schedule Permanent Camp Annual Permit Fee $50.00+ Number of Employees �V 0 a $17.00 each=$ 3, 00 ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$34.00 each=$ Fee must be submitted with Application }��IHSO 0� TOTAL FEE DUE$ �A "V Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1, Part 1, Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name Lf//S /r{�-� Title El❑ Partnership (Please PRINT or TYPE) El Corporation Address e `Oj 1 ir1 GA 939c17 Phone ��• 2�2•3S2 00 Applicant Signature Date of Application 17 y Amount Paid r�Date o ayme�nt1 -----,Payment Type C1her,, eceipt# Received By Account ID 3 I 1 5 C 2/2D 12—! C e—J�_ 1 J 4 0053402 Facility ID Program Record ID P/E Assigned to PWS ID FA0027596 PR0548338 2765 3611 -GIRARDI N/A Report#:7066 Application Printed:11/1/2023