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GE3[EC���M�D PAY <br /> San Joaquin County-Environmental Health Department EIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 <br /> MAR 18 2024 NOV Z 2 2023 <br /> ENVIRONMENTAL HEALTH APPLICATION SAN ENVVIRIROCOUNTY <br /> ONNMM ENTAL <br /> PERMIT/SERVICES IT EN I R NMENOPERATETH HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year d Z <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID# 0025872 <br /> *Additional Employees <br /> State ID#: <br /> EH ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: G&H DAIRY Location: 16996 S SEXTON RD, ESCALON <br /> Operator: G&H DAIRY <br /> Mailing Address: 16996 SEXTON RD, ESCALON CA 95320 Facility Phone#:(209)838-8685 <br /> Legal Owner: VAN DE POL,GERARD New Owner? ❑Yes ❑ No <br /> Owner Address: 16996 SEXTON RD,ESCALON CA 95320 owner Phone rt:k'20a)636-86eoEni: _— <br /> Community Facilities Provided by Camp: Community Kitche^, rjJ 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 _/_/ to_/ / Crop <br /> Apartments <br /> Owner Owned MH/RV iA ` 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 NL <br /> e <br /> TOTALS 0 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 n <br /> ❑ Permanent Camp Annual Permit Fe $50.00+ Number of Employees �_ @$17.00 each=$ L <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$ <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 �i.>t t � � CW V0 k fbf CV-VVA 'p&jryTitle «W Aff Varmership <br /> (Please PRINT or TYPE) f [:1 Corporation <br /> Address <br /> Address ligOA &K"o PhoneUq_j % <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By ,Account ID <br /> IT-423 �I��Z� I�)UU i 12'21 0003056 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0003479 PR0542343 2765 0039-GOODERHAM WA0515704 <br /> Report#:7066 Application Printed:11/1/2023 <br />