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PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> JAN 10 2023 <br /> APPLICATION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ENVIRONMENTAL HEALTH HEALTH DEPARTMENT <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) kAnnual Permit for Calendar Year <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#: 0027815 <br /> *Additional Employees <br /> State ID#: <br /> EH ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: BONNIE PLANTS Location: 23975 E MILTON RD, LINDEN <br /> Operator: DE LA MADRID,MIGUEL <br /> Mailing Address: 23975 E MILTON RD, LINDEN CA 95236 Facility Phone#:(619)664-6921 <br /> Legal Owner: DE LA MADRID,MIGUEL New Owner? ❑Yes o <br /> Owner Address: 23975 E MILTON RD, LINDEN CA 95236 Owner Phone#:(619)664-6921 <br /> Community Facilities Provided by Camn: Community Kitchen? Yes ❑ No <br /> 13 <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Bmldin Employees Q' <br /> Dormitories from p /(u/ ;)3 to A 13 p Crop VS5&tSLAvz&5 <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 Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS 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 /> 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 ' (r/7 <br /> Permanent Camp Annual Permit Fee $50.00+ 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 $100.00+ 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-adressed Envelope <br /> MAKE CHECKS PAYABLE to HID <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 I, Division 13 of the California Health <br /> and Safety Code and Chapter 1, 3,T' le 25,Cal�ria Code ofRegalations. <br /> Applicant Name 1�yL Title ��(� a� 01AA)"I ❑ Partnership <br /> (Please PRINT or TYPE) corporation <br /> Address d�31 S` /(,� �, ` t7� Phone <br /> Applicant Signature Date of Application ! <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> z37,60 T6/ 3� Cxed4 JSY�7� 0050073 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0026344 PR0546475 2765 9834-SUSZYCKI N/A <br /> Report#:7066 Application Printed:11/28/2022 <br />