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- San Joaquin County-Environmental Health Department PgyMENTc <br /> 1868 E Hazelton Ave-Stockton CA 95205-Phone: 209-468-3420 a ceveo <br /> APPLICATION 9 2�26 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE NWHEALj�yRONIME q�� <br /> EMPLOYEE HOUSING OR LABOR CAMP E ^c <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit for Caleniftaf ENT <br /> ❑ Amended Permit *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> State ID#: ' <br /> Please mote any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: EMPIRE FARM LABOR CONTRACTOR LLC- Location: 9167 CONNIE AVE STOCKTON <br /> Operator. EN1PIItE F_MLVI LABOR CONTRACTOR LLC-SIP9eW'P@TF Email: O k Cz C4-(, <br /> Mailing Address: 17450 AVENNIDA LOS ALTOS,SALINAS CA 93907 Facility Phone#: (707)580-1105 <br /> Legal Owner: MARIA LUISA New Owner? ❑ Yes [R No <br /> Owner Address: 9167 CONNIE AVE Owner Phone#: (707)580-1105 Email: <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: NumberofToilets Number of Showers Number of Lavatories 1 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from 03 /30/ 2fa to k'L /21 / 'Zra Crop &1%2fgr I Ch«f i-S,o7rV" <br /> SF Dwellings ' L_ from / / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year 21 b <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 <br /> Ey"permanent Camp Annual Permit Fee $54.00+ Number of Employees V @$17.00 each=$ c�O ' <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 DUE$ <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 provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Code ofReaulations. <br /> Applicant Name Ro r r e r e-- Title ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address I-) tj S0 itvt ra G(y�. La.5 Or l-MS Sits-A C* Vf C7 Phone $31•2-7 2.3 S2,3 <br /> Applicant Signature Date of Application Q 2 • 03.2(o <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By <br /> to <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> A0004262 R2500459 darn Salinas <br /> s� <br /> Report#:7067.rpt <br />