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PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 <br /> FFR 2 6 2n <br /> APPLICATION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH ENVIRONMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) E5Annual Permit for Calendar Year 0%0-_y <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#: 0027507 <br /> *Additional Employees <br /> State ID It: <br /> EH ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form <br /> Site Name: BARRERA MALDONADO PROPERTIES LLC Location: 1108 ROSE MARIE LN,STOCKTON <br /> Operator: BARRERA. LUIS <br /> Mailing Address: 17450 AVENIDA LOS ALTOS, SALINAS CA 93907 Facility Phone#:(831)272-3523 <br /> Legal Owner: BARRERA. EDGAR 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 of Toilets 1 q Number of Showers (`1 Number of Lavatories N <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees <br /> Dormitories from vy lal / to 12 /31 / 2y Crop fihpCrtw ,6hy�S.�p�QrS. <br /> SF Dwellings from _/ / to_/ / Crop <br /> Apartments I '1 <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 <br /> Note <br /> TOTALS 1 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 <br /> B-11,11ermanent Camp Annual Permit Fee $50.00+ Number of Employees 1�k @$17.00 each=$ 02 IA(o 0 0 <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$ �)el.(pQ , 00 <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 LUjS L /i-C�e._ Title -f Partnership <br /> (Please PRINT or TYPE) <br /> �u/�-7� Q ,�,�C �Q q ❑Corporation <br /> Address OM Ave,/I /�� Z z �l 17� . &4'/inqA- (.T l /�CF? Phone C�73/_ 212 - 3S2-21 <br /> Applicant Signature Date of Applicati0n Q� •/� .� <br /> Amount Paid Date of ayment Payinen Type Check/ eceipt# Received By Account ID <br /> aLi r 0049219 <br /> Facility ID Program Record ID PIE IrJ Assigned to PWS ID <br /> FA0025974 PRO545931 2755 9834-SUSZYCKI N/A <br /> Reoort#:7066 Application Printed:11/1/2023 <br />