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San Joaquin County-Environmental Health Department <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year `� <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator.Address *Change of Owner Address Permit ID#: 0000587 <br /> *Additional Employees <br /> State ID#: 39-0001-EH <br /> EH ID#• 39000001 <br /> Please Note any Corrections or Changes in Facility/Operator Infionnation directly on this form. <br /> Site Name: CANAL RANCH 39-1 Location: 23187 N BLOSSOM RD,THORNTON <br /> Operator: CANAL RANCH FARMS INC <br /> Mailing Address: 11292 N ALPINE RD,STOCKTON CA 95212 Facility Phone#:(209)948-0792 <br /> Legal Owner: CORTOPOSSI PARTNERS LP New Owner? ❑Yes ❑ No <br /> Owner Address: 11292 N ALPINE RD,STOCKTON CA 95212 Owner Phone#:(209)948-0792 <br /> Communitv Facilities Provided by Camp: Community Kitchen? ❑ Yes No <br /> 11-41 <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 /> Buildings Employees <br /> Dormitories from _L/_L/2�to Crop <br /> SF Dwellings j(� 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 'l Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces —G�— Note PAYMENT <br /> �C <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a yyECEIVED <br /> Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive APR 01 2024 <br /> Important: In order to protect your land use status,if camp will not he used this year but is intended for use in the future,Check this Box and return this application. <br /> NMENTAL Y <br /> Fee Schedule HEALTH DEPARTMENT <br /> ® Permanent Camp Annual Permit Fee $50.00+ a p cl ,>,2 Number of Employees 1 @$17.00 each=$ �� J <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee S25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employers @$34.00 each=$ <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 ��Y�GC� 1CtC t'l�S �4\C_ Title r��y����11e � ❑Partnership <br /> (Please PRINT or TYPE) Q Corporation <br /> Address -J Phone <br /> Applicant Signature Date of Application <br /> Amount 71d Dat of yment Payment Type Check/Receipt# Received By Account ID <br /> 0000581 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0000582 PR0270001 2765 0039-GOODERHAM WA0515734 <br /> Report#:7066 Application Printed:3/28/2024 <br />