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San Joaquin County-Environmental Health Department <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <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) CR Annual Permit for Calendar Year _ <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0010958 <br /> *Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000328 <br /> Site Name: VANDER SCHAAF DAIRY#1 39-328 Location: 12739 S MURPHY RD, ESCALON <br /> Operator: VANDER SCHAAF DAIRY <br /> Mailing Address: 13749 MURPHY RD, ESCALON CA 95320 Facility Phone#:(209)838-3947 <br /> Legal Owner: VANDER SCHAAF, EARL JOHN,SUSAN,JOSEPH, DAVID New Owner? ❑Yes ❑ No <br /> Owner Address: 13749 MURPHY RD, ESCALON CA 95320 Owner Phone#:(209)595-7687 <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 /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees <br /> Dormitories from /_/ to_/_/ Crop <br /> SF Dwellings from 4 to_/3L_/_ A Crop 1pet4, <br /> Apartments <br /> Owner Owned ME/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: irwo <br /> ME/RV Spaces Note ECEI N EL <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit E <br /> I ' 0 0 202,3❑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.SAN JOAQUIN COUN <br /> Fee Schedule HEALTH DE IMUNMENTAL_ <br /> PARTMEIy <br /> Permanent Camp Annual Permit Fee $50.00+ Number of Employees �7 @$17.00 each=$ <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 /> t <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ 9 <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 yaijer _�C Ao Title ©l ynr/ 0 P/artnership <br /> (Please PRINT or TYPE) r"�'I ❑Corporation <br /> Address 13 7 19 m wp y f S �i�y, L Phone� � y R��j 2 <br /> Applicant Signature �� Date of Application <br /> 1 <br /> Amount Paid D to of P yment Payment Type Check/Receipt# Received By Account ID <br /> / 1 a 2 55 0003042 <br /> Facility ID o[Program Record ID P/E J Assigned to PWS ID <br /> FA0003465 PR0515602 2765 0039-GOODERHAM WA0515649 <br /> �QD � ( <br /> Report#:7066 �gppiication Printed:11/1/2023 <br />