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San Joaquin County-Fnvironmental Health Department <br /> 1868 F Hazelton Ave-Stockton CA 9520.5-Phone: 209468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP !1 1 <br /> ❑Nrw fang) ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® ,lnnuad Perm dait for c.iien . Ycatr 2026 <br /> ❑ Amended Permit: "Change of Operator "Change of()vner <br /> "Change of Operator Address "Change of OW ner Address <br /> "Additional Employees <br /> State 11)#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: FRANK N ROCHA DAIRY LP#139-345 Location: 23243 E LONE TREE RD ESCALON <br /> Operator: FRANK N ROCHA DAIRY LP#1 39-345 Email: <br /> Mailing Address: 23125 E LONE TREE RD,ESCALON CA 95320 Facility Phone#: (209)838-1297 <br /> Legal Owner: ROCHA,FRANK N AND KATHY,SILVA,JOHNNY,& New Owner? ❑ Yes ❑ No <br /> MEGAN <br /> Owner Address: 23125 E LONE TREE RD,ESCALON CA 95320 Owner Phone#: (209)838-1297 Email: <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: NumberofToilets NumberofShowers Number of Lavatories <br /> Women: NumberofToilets Number ofShowers Number of Lavatories <br /> Ilousin2 Accommodations to be Utilized this Year: Occupancy Dates: <br /> Building Employees <br /> Dormitories from / / to / / Crop <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 <br /> N9S4 <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more clays in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> I ni nurta n t In order to protect your land use status,if camp will not be used this year but is intended for use in die future,Check this Box and return dtis application. <br /> Fee Schedule <br /> ❑ Permanent Camp Annual Permit Fee $54.00+ Number of Employees @$17.00 each=$ <br /> ❑ "rransferofOwnership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $108.00+ Nwnber of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE S <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 Title ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By <br /> Facility ID Program Record ID PIE Assigned to PINS ID <br /> FA0003360 PR0515635 `76; ena Leltoy <br /> Report#:7067.rpt <br />