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San Joaquin County-Environmental Health Department <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <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 2 0 25 <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID# 0022183 <br /> *Additional Employees <br /> State ID#: 39-15855-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000430 <br /> Site Name: RIPON FARMS 39-430 Location: 23531 S JACK TONE RD, RIPON <br /> Operator: HOGAN,THOMAS P <br /> Mailing Address: 1532 SCENIC DR, MODESTO CA 95355 Facility Phone#:(209)492-9335 <br /> Legal Owner: HOGAN,THOMAS P New Owner? ❑Yes v k/ No <br /> Owner Address: 1532 SCENIC DR, MODESTO CA 95355 Owner Phone#:(209)604-5280 <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: Occunancv Dates: <br /> dldin s Employees <br /> Dormitories from 61 /a( / 2 1'02. / / Crop V <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 /> lY4tg <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 /> $52.00 Fee Schedule <br /> ❑ Permanent Camp Annual Permit Fee + 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$ 1 y <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, bchapter 3,Titl 5,California Code of Regulations. � _ <br /> Applicant Name v � G{ Title - -z� ❑Partnership <br /> (Please PRINT or TYPE) ���� ❑Corporation <br /> Address Zv sore q,6 141 S v <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0037333 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0020798 PR0536203 2765 9852-SALINAS N/A <br /> Report#:7066 Applicatlon Printed:6/32025 <br />