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I PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> DEC 3 0 2024 <br /> APPLICATON <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ENVIRONiNIF.NTALHEALTH HEALTH DEPARTMENT <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP f� <br /> E]NmCamp []Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year_.2025 <br /> ❑Amended Permit: "Change of0perator "Change of Owner <br /> "Change of Operator Address -Change or Owner Address Permit ID M 0029152 <br /> -Additional Employees <br /> State ID#: <br /> Please Nanyote ry Corrections or Changes in Facility/Operator Information directly on this form. Ell 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 ofToilets S Number of Showers �� Number of Lavatories So <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories _ from 64 /01 / ZS to 17-/ 1�� Crop C4�((trjtsI pf\ttJnr,Pe9p J <br /> SF Dwellings from—/—/—to /_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Can Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces <br /> Note <br /> TOTALS Camps Camps occupied by 25 or more Employees for 60 or more days in a year <br /> © - J Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> Important: In order to protect your land use status,ii'camp mill not be used this year but is intended for use in the future.Check this Hos and return this application <br /> Z Fee Schedule <br /> Permanent Camp Annual Permit Fee Number of Employees 200 @ 517.00 each=$ 3 L�S Z •00 <br /> ❑ Transfer of Ownership $25.00 S <br /> ❑ Permanent Amendment Fee $25.00- Number of Additional Employees @$17.00 each=S <br /> ❑ Late Application Fee $100.00+ Number of Employees @$34.00 each=$ <br /> Fee must he submitted with Application <br /> TOTAL FEE DUES 3 <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EIID <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 Safery Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name (/L/f-s re(— Title IY�-q tr ❑Partnership <br /> (Please PRINT or TYPE) j _ _` El Corporation <br /> Address 1-745-6 /�45-6 r'f V f ni c Fk LOS ft l los a y�n&e� A t ` 40-7- Phone 6W 2-1-1_ 5 Z3 <br /> Applicant Signature Date of Application 1'-2-•2 6P Ll <br /> Amount <br /> Amount Paid Date of Payment Pay nt Type Check/Receipt# Received By Account ID <br /> 3185 2. bD 0053402 <br /> Facility ID I Program Record ID PIE Assigned to PWS ID <br /> FA0027596 PR0548338 2765 0034-AHMED NIA <br /> Report# 7066 *PAR- �,$I 25 Application Printed:10/28/2024 <br />