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San Joaquin County- Environmental Health Department 1868 E Hazelton Ave- Stockton CA 95205-Phone: 209-468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP❑New Camp E]Conditional Permit E] Multiple Years(Permanent Housing Camps only) ® Annual Permit for Calendar Year 2026 ❑ Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees State ID #: Please Note any Corrections or Changes in Facility/Operator Information directly on this form. Site Name: EMPIRE FARM LABOR CONTRACTOR LLC- Location: 4219 E WATERLOO RD STOCKTON STOCKTON INN Operator: EMPIRE FARM LABOR CONTRACTOR LLC-STOCKTON Email: 0'x c-Y C . @ f� INN '� ` "ems C.d M Mailing Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Facility Phone#: (209)931-3131 Legal Owner: EMPIRE FARM LABOR CONTRACTOR LLC New Owner? ❑ Yes WN0 Owner Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Owner Phone#: (831)272-3523 Email: tY. ' mb Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets '5u Number of Showers SO Number of Lavatories C� Women: Number of Toilets 5 .7 Number of Showers 50 Number of Lavatories50 Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories 5 'LO O from 01 l U /Z� to IZ 131 / 2 Crop ( I�itJ 0 Q �l 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: 10� MH/RV Spaces Note TOTALS too 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 die future,Check this Box and return this application. Fee Schedule 4�2 Permanent Camp Annual Permit Fee $54.00+ Number of Employees Oa @$17.00 each=$ 3/4 SH •0 6 ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ ❑ Late Application Fee $108.00+ Number of Employees @$34.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 1 ILJ5LJ . V6 Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed 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 -*frith 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 ofRegulaiions. Applicant Name Luis ijpUrtrx,_ Title �'> / ❑Partnership (Please PRINT or TYPE) ❑ Corporation Address 0 Ll sp #WtA i &tr— Los RAIV S Sojj 04.5 CA 9901 d-+ Phone ��) 21 I--35 2-3 Applicant Signature Date of Application j Z-[� •��j Amount Paid Date of Payment Payment Type ChecktReceipt# Received By F cility ID P ogram Record ID PIE Assigned to PWS ID FA0027596 PR0548338 765 .�M�N`` Sastina Thanunavonasa Report#: 7067.rpt ]AN 1 2 N ;AN JOAOIIIN coUN 1Y ,INVIVIC)W1LN A i.