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I-ATMtNT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E.Hazelton Avenue-Stock-ton CA 95205-Phone: 209-468-3420 <br /> JUL 2 8 2n25 <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) ,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 /> EH ID#: 39000328 <br /> Please Note any Corrections or Changes in FacilityiOperator Information directly on this form. <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 /> OwnerAddress: 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 /> Buildings Employees <br /> Dormitories from /�/ to / / Crop <br /> SF Dwellings from _/_/ to / / Crop <br /> Apartments <br /> Owner Owned ME/RV Total Number of Days to be used this Calendar Year: Cs <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces <br /> 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 p�r <br /> ❑ Permanent Camp Annual Permit Fee $56.00+ 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 /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ I <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> M,,kI E 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 �1Grnt'S J/fit sr� 7'- Title P � El Partnership <br /> (Please PRINT or TYPE) '`T <br /> ❑Corporation <br /> Address /3 7 <br /> Phone <br /> t <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received ey Account ID <br /> 0003042 <br /> rCX011L J <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0003465 PRO515602 2765 9852-SALINAS WA0515649 <br /> Reoort#:7066 Application Printed:6/4/2025 <br />