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San Joaquin County-Environmental Health Department PA <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 REG+Mc NT <br /> LIVED <br /> APPLICATION V 2 O 2023 <br /> ENVIRONMENTAL HEALTH SA JOAQUIN <br /> PERMIT TO OPERATE ENVIRO BOUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP HEAL?-H DEMENTA <br /> ❑New Camp []Conditional Permit ❑ Multiple Years(Permanen[Housing Camps only) Annual Permit for Calendar Year�T <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0010991 <br /> *Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in FacilitvlQpe• ,or Information directli,on this form. EH ID#: 39000345 <br /> Site Name: FRANK N ROCHA DAIRY LP#1 39-345 Location: 23243 E LONE TREE RD, ESCALON <br /> Operator: ROCHA, FRANK N <br /> Mailing Address: 23125 E LONE TREE RD, ESCALON CA 95320 Facility Phone#:(209)838-1297 <br /> Legal Owner: ROCHA, FRANK NAND KATHY,SILVA,JOHNNY,&MEGAN New Owner? ❑Yes No <br /> Owner Address: 23125 E LONE TREE RD,ESCALON CA 95320 Owner Phone#:(209)838-1297 <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 Ire Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from_L/0)/t^W to 1.& /31,21VJ Crop l <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,ifcamp will not be used this year but is intended for use in the future,Check this Box and return this application. <br /> Fee Schedule 1 <br /> W/Permanent Camp Annual Permit Fee $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 DLIE$ -O <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EIID <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 FKA •�O`2'A•� Tit[ E N � Mf Partnership <br /> (Please PRINT or TYPE) " '- �� ��" <br /> El <br /> AddressNLI F. 4 Phon �nq, �� <br /> Applicant SignatureAn� Date of Application '�•��--�-� <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> I d/ � I` y 1� Q�/ 0002937 <br /> IFacility ID Program Record ID 1J1�P/E U to Assigned to PWS ID <br /> FA0003360 PR0515635 2765 0039-GOODERHAM WA0515607 <br /> 3 �v�'a <br /> Report#:7066 Application Printed:11/l/2023 <br />