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P - - .-�k� <br /> RAYNESan Joaquin County-Environmental Health Department R�M�'-N?' <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 ` i�o <br /> APPLICATION I ,jo <br /> SAN JOAQUIN COUNTY ENVIItONMENTAL HEALTH JE II / QUID/C <br /> �E�N�VIRONMENTAL NT EMPLOYEE HOUSING ORPERMIT TO LABOR CAMP NETE ALT N O PARTMFNT y <br /> New <br /> FATHCamp <br /> DEPq}ZTLJ Conditional Permit Multiple Years(Permanent Housing Camps only) 11 I`IT <br /> iL�'J?" ❑ g P Y) Annual Permit for Calendar Year YOy� <br /> ❑Amended Permit: "Change of Operator "Change of Owner <br /> "Change of Operator Address "Change of Owner Address <br /> *Additional Employees Permit ID M 0025872 <br /> State ED#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ED#: <br /> Site Name: G&H DAIRY J LLC 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#:(209)838-8685Ext: <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_/_/ to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV j-4 Z 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 <br /> Note <br /> TOTALS j 0 Camps occupied by 25 or more Employees for 60 or more days in a year <br /> 1 <br /> El Inactive Require a PUBLIC WATER SYSTEM Permit <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 <br /> Permanent Camp Annual permit Fee <br /> Number of Employees (a�$17.00 each=$ I <br /> ❑ Transfer of Ownership <br /> $25.00=$ <br /> EJPermanent Amendment Fee <br /> $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 2� <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 a <br /> and maintained in accordance with the applicable PP groes that this project (camp) shall be operated <br /> pp provisions of the EMPLOYEE HOUSING ACT, Chapter 1, Part 1, Division 13 of the California Health <br /> andSafety Code and Chapter 1,Subchapter 3,Title 25,Californiaa Code of Regulations. <br /> Applicant Name 7d N f�1,C,Title /� 'r Q! <br /> (Please PRINT or TYPE) -iV T� V W nG1 ❑Partnership <br /> Address W qq W B Sey-+-D ` _ '-1�., ElCorporation <br /> ('1 �' �S(_.(I� ' S� Phone ���� <br /> Applicant Signature <br /> Date of Application <br /> Amount Paid Date of Payment Payment Type Ch ecei t# <br /> l P Received By Account ID <br /> �W• 0003056 <br /> Facility ID Program Record ID PIE <br /> Assigned to PWS ID <br /> FA0003479 PR0542343 2765 9852-SALINAS <br /> ,L::: WA0515704 <br /> Report#:7066 <br /> Application Printed:10/28/2024 <br />