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San Joaquin County-Environmental Health Department <br /> 1868 E 1-lazelton Ave-Stockton CA 95205-Phone: 209468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit for Calendar Year 2026 <br /> ❑ Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> State ID#:39-0120-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: HJS SOLIS 39-120 Location: 13631 N HURD RD LODI <br /> Operator: HJS SOLIS 39-120 Email: <br /> Mailing Address: PO BOX 1201,LODI CA 95241 Facility Phone#: (209)271x360 <br /> Legal Owner: SOLIS-LUNA,HECTOR New Owner? ❑ Yes ❑ No <br /> Owner Address: PO BOX 1201,LODI CA 95241 Owner Phone#: (209)271-8360 Email: <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets NumberofShowers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories L <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees <br /> Dormitories from / / to / / 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: <br /> MH/RV Spaces Note <br /> TOTALS 4 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 l t%l� <br /> CR Permanent Camp Annual Permit Fee $54.00+ Number of Employees @$17.00 each=$ .� q A{ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $108.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application p <br /> TOTAL FEE DUE$ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed 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 and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name �'C7 2 S 15 a/) L [ t//? Title l `��e ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address f✓� �� /1 il- 9360 <br /> Applicant Signature � � Date of Application <br /> Amount Paid Date of P yment Payment Type Check/Receipt# Received By <br /> 2P- <br /> Facility ID Program Record ID PIE Assigned to WS ID <br /> FA0000454 PR0270120 2765 lAaron Gooderitam <br /> Report#:7067.rpt l <br /> N�PN- <br /> N� <br />