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PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E Hazelton Ave-Stocktuon CA 95205-Phone: 209-468-3420 <br /> APPLICATION U V <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE "N JOAgV11V COUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP H'E�WR�O�NAIEp AL <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit ffoor(aRJ?4RT!!0& <br /> ❑ Amended Permit: "Change of Operator "Change of Owner <br /> "Change of Operator Address *Change of Owner Address <br /> "Additional Employees <br /> State ID#:39-15855-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: VANDER SCHAAF DAIRY 42 39-364 Location: 15355 S VAN ALLEN RD ESCALON <br /> Operator: VANDER SCHAAF DAIRY#2 39-364 Email: oLme_4 vs jed •vet•-eo nI <br /> Mailing Address: 13749 MURPHY RD,ESCALON CA 95320 Facility Phone#: (209)8383947 <br /> Legal Owner: VANDER SCHAAF,EARL JOHN,SUSAN,JOSEPH, New Owner? Yes OKN. <br /> DAVID <br /> t <br /> Owner Address: 13749 MURPHY RD,ESCALON CA 95320 Owner Phone#: (209)595-7687 Email: A if to OkItI140in <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: NumberofToilets 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 19 '�_ from I / l /A& to a/3 l/" 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 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 I nL7 <br /> Permanent Camp Annual Permit Fee $54.00+ Number of Employees _ @$17.00 each=$ `[ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $108.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application % <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 ,7 I/,,.,4r —<C Title er Partnership <br /> l�1rS <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address fI �SC-i CA Phone --20g- t f)?Q g <br /> Applicant Signature Date of Application l� — <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0003470 )765 Rena LeRo} <br /> Report#:7067.rpt <br />