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PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E Hazelton Ave-Stockton CA 9i20i-Phone: 209468-3420 F B 0 5 2026 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit for Calendar Year 2026 <br /> ❑ Amended Permit: *Change of Operator *Change of Owner <br /> "Change of Operator Address *Change of Owner Address <br /> *:additional Employees <br /> State ID#:39-0040-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: LARSEN RANCH 3940/WATER SYSTEM Location: 5125 S KAISER RD STOCKTON <br /> Operator: LARSEN RANCH 39-40AVATER SYSTEM F,mail: <br /> Mailing Address: PO BOX 4403,MANTECA CA 95337 1 aciIit. Phone 4: (209)851-5650 <br /> Legal Owner: LARSEN,BARBARA NC1r ON%[lei :' ❑ Yes ❑ No <br /> Owner Address: PO BOX 4403,MANTECA CA 95337 Owner Phone 9: (209)851-5050 Email <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes 1,:2_No <br /> Men: Number ofToilets NumberofShowers Number of Lavatories <br /> Women: NumberofToilets Number of Showers Number of Lavatories <br /> Housino:kccoinmodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees ` <br /> Dormitories from / / to 9 Q Crop - S <br /> SF Dwellings from / / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: -2 <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 l J <br /> Permanent Camp Annual Permit Fee $54.00+ Number of Employees `yam @$17.00 each=$ t� , J�_ <br /> ❑ 'Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ [ate Application Fee $108.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUES <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 provis s of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and <br /> Safeti'Code and Chapter 1,S Ater 3 Title 25,Cali oyn Code ofReguladons. <br /> .Applicant Name Title ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address ry Phone G4T 08 <br /> %pplicalit sil"naturc A JL Date of Application <br /> Amount Paid Date of Payment Payment Type Cheek/Recelpt it Received By <br /> a& ak 215�3 <br /> d-- <br /> Facility ID Program Record ID PIE Assigned to PVVS ID <br /> FA0002805 11RO270040 _176> \aain;t Thamnut ones;t <br /> Report#:7067.rpt <br />