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REc `1V GD ., oaquin County - Environmental Health Depa ► k : <br /> a� 2o'Z1 1868 E. Hazelton Avenue - Stockton CA 95205 - Phone : 209-468-3420 {] iJ <br /> anet <br /> SP E�v1RpNMER MENT APPLICATION I 4 °' � <br /> N�`1` 10EPP ENPERMITITO OPERATEENTAL TH EN PIRONMENTAL HEALTH <br /> EMPLOYEE HOUSING OR LABOR CAMP ERMIT/SERVIOES <br /> ❑ New Camp ❑ Conditional Permit ❑ 11lultiple Yea rs (permanent dousing Camps only) Annual Permit for Calendar Year AD <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 it: <br /> EH ID #: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this forlll. <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 No <br /> Owner Address: 23975 E MILTON RD , LINDEN CA 95236 Owner Phone #: (619)664-6921 <br /> Community Facilities Provided by Camp : Community Kitchen ? ® Yes ❑ No <br /> Men : Number of Toilets Number of Showers Number of Lavatories <br /> Women : Number of Toilets Number of Showers Number of Lavatories <br /> Horsine Accommodations to be Utilized this Year: Occupancy Dates : <br /> Buildines Emplovees <br /> Dormitories from _/ jf;l k 2 to /�(/ Z Crop <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: NT <br /> MNote H / RV Spaces EIVED <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> �? Require a PUBLIC WATER SYSTEM Permit $ 2 2qq1 <br /> El 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 Bos and return this app re4 ?AQUIN COUNTY <br /> Fee Schedule HEALTH DEPARTMENT <br /> ® Permanent Camp Annual Permit Fee $50.00 + Number of Employees (t9 @ $ 15 . 00 each = $ <br /> ❑ Transfer of Ownership $25 . 00 = $ <br /> ❑ Permanent Amendment Fee $25 .00 + Number of Additional Employees @ $ 15 . 00 each = $ <br /> ❑ Late Application Fee $ 100, 00 + Number of Employees @ $30. 00 each = $ ,(?� <br /> Fee must be submitted with Application t� <br /> TOTAL FEE DUE $ A. <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <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 Safety Code and Chapter 1 , Subchapter 3 , Title 25, California Code of Regulations. <br /> Applicant Name e / CA VA, Title S r4 rl t" 4P*ijg (162 ❑ Partnership <br /> (P/ease PRINT or TYPE) 5ZCorporation <br /> Address Aj LZ12j jA) 060j CA g5X3 (a Phone L� 31 ) 3 > e — ( 60 0 <br /> Applicant Signature / Date of Application ! 0 j a <br /> Amount Paid Date of Payment Payment Type Check/Receipt # Received By Account ID <br /> 0050073 <br /> 2 � 0 — Z8 ,, ( 9 o8 �_ <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0026344 PR0546475 2765 9834 - SUSZYCKI N/A <br /> Report #: 7066 Application Printed : 12/2/2021 <br />