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PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> ED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <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 bear z L <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#: 0028888 <br /> *Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: <br /> Site Name: STERLING FARMS LLC Location: 22220 N HWY 99,ACAMPO <br /> Operator: BURNETT,TODD <br /> Mailing Address: 17250 E KETTLEMAN LN, LODI CA 95240 Facility Phone#:(209)401-5177 <br /> Legal Owner: BURNETT,TODD New Owner? ❑Yes No <br /> OwnerAddress: 17250 E KETTLEMAN LN, LODI CA 95240 Owner Phone#:(209)401-5177 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets - 3 Number of Showers 2 j g RTIti 1,,,a""'Number of Lavatories 13 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occunancv Dates: <br /> Buildines Employee s <br /> Dormitories from (l lto U l�/l �� Crop L/I�E37oCK A <br /> SF Dwellings ` from _/_/ to / / 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 SU• lu <br /> Permanent Camp Annual Permit Fee $50.00+ 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 $100.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ ( -3 <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. LJ/11rrb 14ACILI-r <br /> Applicant Name ?O�� C 13 R(� �T Title ❑Partnership Czr7 ei1 v y <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address 17z5-0 ETILCli Liv Lc ID) C# 61�-2 J Phone 2jc j LION—5177 <br /> Applicant Signature Date of Application 1/1 z— <br /> Amount Paid Date of Payment Payment Type Chec eceipt# Received By Account ID <br /> I� � c � 0052710 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0027372 PR0547994 2765 8987-SANGALANG N/A <br /> Report#:7066 Application Printed:11/1/2023 <br />