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San Jo.-4uin Co;tnty-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) [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# 0011895 <br /> *Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000364 <br /> Site Name: VANDER SCHAAF DAIRY#2 39-364 Location: 15355 S VAN ALLEN RD, ESCALON <br /> Operator: VANDER SCHAAF DAIRY#2 <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 /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees <br /> Dormitories from _/_/ to_/ / Crop <br /> SF Dwellings from I / 1 / &.I to 0,/ 3//l Crop J;Jx f).tr <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: PAY ENT <br /> MH/RV Spaces Note RECEIVED <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit DEC 0 6 2023 f <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 applicasm JOAQUIN COUNTY <br /> MENTAL <br /> Fee Schedule LHLEALTH DEPARTMENT <br /> QJ Permanent Camp Annual Permit Fee $50.00+ Number of Employees _ @$17.00 each=$ -3G <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 S /Qb <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,'I'itle 25,California Code of Regulations. <br /> Applicant Name Ua"'Je'- Se�aa1� �a,�.y Title oe;��.r Partnership <br /> (Please PRINT or TYPE) Q 1�i�1 El Corporation <br /> Address 13 7Y � fio,".Ok f$r��on G� Phone(;)OV m, <br /> Applicant Signature ( ,!2_ Date of Application �- <br /> Amount Paid D1 of Payment Payment Type Check/Receipt# Received By Account ID <br /> CIL <br /> 0003047 <br /> v(/ <br /> 7FAFacility ID Program Record ID PIE Assigned to PWS ID <br /> 0003470 PR0518188 2765 0039-GOODERHAM WA0515627 <br /> -5qo -� c Z Report#:7066 Application Printed:11/1/2023 <br />