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San Joaquin County - Environmental Health Department PA IVr <br /> 1868 E . Hazelton Avenue - Stockton CA 95205 - Phone : 209-468-3420 FMCED <br /> rA <br /> APPLICATION SAN JOi4QUIN COUNTY <br /> ENVIRONMENTAL HEALTH ENVIRONMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑ New Camp El Conditional Permit <br /> ❑ Multiple Years (Permanent Housing Camps only) Annual Permit for Calendar Year <br /> ❑ Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees Permit ID # : 002 $ $ $ $ <br /> State ID # : <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID # : <br /> F111a <br /> Name : STERLING FARMS LLC <br /> Location : 22220 N HWY 99 , ACAMPO <br /> ator : BURNETT, TODD <br /> gAddress: 17250 E KETTLEMAN LN , LODI CA 95240Facility Phone #: (209)401 -5177 <br /> Owner: BURNETT, TODD <br /> New Owner ? Yes No <br /> rAddress : 17250 E KETTLEMAN LN , LODI CA 95240 <br /> Owner Phone # : (209 )401 -5177 <br /> Community Facilities Provided bxiCamajCommunity Kitchen ? ❑ Yes ❑ No <br /> Men : Number of Toilets Number of Showers -� J 16 (IT <br /> Women: Number of Toilets umber of Lavatories <br /> Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year <br /> Occunancv Dates : <br /> Buildings Em <br /> Dormitories <br /> Dormitories from <br /> / f / to 12 /31 / Crop L/ V !OCI �p l4 <br /> SF Dwellings � �0 ' from / / to / / <br /> Apartments — Crop <br /> Owner Owned MH / RV <br /> Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars <br /> MH / RV Spaces <br /> Total Days Occupied by 25 or more Employees : <br /> Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> ❑ Inactive Require a PUBLIC WATER SYSTEM Permit <br /> 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. <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fee $50 , 00 + <br /> Number of Employees @ $ 17. 00 each <br /> ❑ Transfer of Ownership <br /> ❑ Permanent Amendment Fee $25 . 00 + $25 . 00 = $ <br /> Number of Additional Employees @ $ 17. 00 each = $ <br /> ❑ Late Application Fee $ 100000 + Number of Employees <br /> @ $34. 00 each = $ <br /> Fee must be submitted with Application <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> TOTAL DUE S <br /> ?j <br /> MAKE CHECKS PAYABLE to EDD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE . Applicant agrees that this project (cam ) shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE DOUSING ACT, Chapter 1 , Part 1 , Division 13 of the Cali ornia Health <br /> and Safety Code and Chapter 1 , Subchapter 3 , Title 25, California Code ofRegulatious. f <br /> Applicant Name Q b � Iii Title �t ry <br /> (P/ease PR/NT or TYPE) ❑ Partnership Ca F? PAmI <br /> , ' ��Q;, El Corporation <br /> Address <br /> �ITL�/.'J� L �l � .i� l � � �^ y�� Phone2E� <br /> Applicant Signature <br /> NINE MEN <br /> Date of Application I <br /> Amount PaidIIIIIIIIIIIIIIIN <br /> Date of Payment Payment T ^ <br /> Y Type 'Check/Receipt # Received B <br /> 9 f J r f Y Account ID <br /> �, <br /> i - 0052710 <br /> Faci11 lity ID Program Record ID <br /> PIE11 LE: Assigned to PWS ID <br /> FA0027372 PR0547994 2765 <br /> 8987 - SANGALANG N/A <br /> Report #: 7066 <br /> 3 �b3 <br /> Application Printed - 11 /1 /9no � <br />