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PAYMENT <br /> San Joaquin County-Erivironmental Health Department RECEIVED <br /> 1868 E Ilazelton Ave-Stockton CA 95205-Phone: 209468-3420 F B 0 5 20 <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-E11 <br /> Please Note any Corrections or Changes in Facility/Operator information directly on this form. <br /> Site Name: LARSEN RANCH 3940AVATER SYSTENI Location: 5125 S KAISER RD STOCKTON <br /> Operator: LARSEN RANC11 39-40AN'ATER SYSTENI Email: p <br /> Mailing Address: PO BOX 4403,NIANTECA CA 95337 Facility Phone#: (209)851-5650 r bit Oil J.17 <br /> Legal Owner: LARSEN,BARBARA New Owner? ❑ Yes No <br /> Owner Address: PO 13OX 4403,MANTECA CA 95337 Owner Phone#: (209)851_5650 Email:I0.r In <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes -a No <br /> Men: NumberofToilets NumberofShowers Number of Lavatories <br /> Women: Number of Toilets NumberofShowers Number of Lavatories <br /> Ilousiit-Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees ` / <br /> Dormitories from / / to Y l p Crop l 9 P S <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 to <br /> TOTALS Camps occupied by 25 or more Employees for60 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 1 <br /> f <br /> 14. Permanent Camp Annual Permit Fee $54.00+ Number of Employees y(` @$17.00each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $108.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUES l) <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed Envelope <br /> MAKE CHECKS PAYABLE:to F.HD <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(lie applicable provis' s of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and <br /> Safet}•Code and Chapter 1,S pter 3 Title 25,Cali oi4j Code ofRegalations. <br /> Applicant Name Title Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address Phone QB�� <br /> Applicant Signature t_ Date of Application 4p <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By <br /> TF 12CO 215?2;ffi3 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> F A0002805 11RO270040 2765 Sastina Thanuuai ongsa <br /> Report#:7067.rpt <br />