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` YM San Joaquin County-Environmental Health Department Pg PA EIVT 1868 E Hazelton Ave-Stockton CA 95205-Phone: 209-468-3420 G EIVEp APPLICATION (� Z026 ENVIRONMENTAL HEALTH PERMIT TO OPERATE 'AN JOAQUIN CO EMPLOYEE HOUSING OR LABOR CAMP ENWRO UNTy HEALTF� E MAI ❑New Camp ❑Conditional Permit ElMultiple Years(Permanent Housing Camps only) ® Annual Permit for Calenda ENr ❑ Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees State ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on this form. Site Name: EMPIRE FARM LABOR CONTRACTOR LLC- Location: 9167 CONNIE AVE STOCKTON Operator: EMPIRE FARM LABOR CONTRACTOR LLC-ffOe'1'f` ON Email: O / e 1 _ r,C �I e � Mailing Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Facility Phone /� K P�honnee#: (707)580-110055 Legal Owner: MARIA LUISA New Owner? ❑ Yes 12 No Owner Address: 9167 CONNIE AVE Owner Phone#: (707)580-1105 Email: Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets 1 Number of Showers Number of Lavatories 1 Women: Number of Toilets Number of Showers Number of Lavatories 1 Housine Accommodations to be Utilized this Year: Occuoancv Dates: Buildings Emplovees Dormitories from U 3 /$0/ 2(e to t L /31 / 2 fo Crop ?tll efe--<- I I✓ht n i-S ,vo-0-5 SF Dwellings ' �_ from / / to / / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 1p Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year © Require a PUBLIC WATER SYSTEM Permit ❑Inactive 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. Fee Schedule nr-*P,ermanent Camp Annual Permit Fee $54.00+ Number of Employees U J @$17.00 each=$ aN '0 0 ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ ❑ Late Application Fee $108.00+ Number of Employees @$34.00 each=$ Fee must be submitted with Application TOTAL FEE DUE S Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name L(/jS 1?0-rr-era-- Title nm2r �,�i� ❑Partnership (Please PRINTor TYPE) v ❑Corporation Address 11 LlSQ AlAe iGte, LoS 41405 S Cg. VfD Phone $3�•2-72.3S2.3 Applicant Signature Date of Application •2.(O Amount Paid Date of Payment Payment Type Check/Receipt# Received By Facility ID Program Record ID PIE Assigned to PWS ID FA0004262 R2500459 Aldara Salinas Report#:7067.rpt tJ