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Of PAy !e VT <br /> San Joaquin County-Environmental Health Department Rey'e'VeD <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 s R.a <br /> APPLICATION �dOAQUI <br /> EN PERMIT TO OPERATE <br /> TH Hggl D PAR ��1Y <br /> EMPLOYEE HOUSING OR LABOR CAMP T <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <br /> ❑Amended Permit: "Change of Operator "Change of Owner <br /> "Change of Operator Address -Change of Owner Address Permit ID#• 0000460 <br /> "Additional Employees <br /> State ID#: 39-0120-EH <br /> EH ID#: 39000120 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: HJS SOLIS 39-120 Location: 13631 N HURD RD,LODI <br /> Operator: SOLIS-LUNA,HECTOR <br /> NI ailing Address: PO BOX 1201,LODI CA 95241 Facility Phone#:(209)271-8360 <br /> Legal Owner: SOLIS-LUNA,HECTOR New Owner? ❑Yes ❑ No <br /> Owner Address: PO BOX 1201,LODI CA 95241 Owner Phone#:(209)171-8360 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets Number of Showers Number of Lavatories 0 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> v <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees <br /> Dormitories from /_/ to_/_/ Crop <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 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 77�� <br /> Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$15.00 each=$ 2I .C>D <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ o (OV <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,Subchapter 3,Title 25,California Code of Regulations. <br /> ) El Partnership <br /> Applicant Name j'('��2 S 0 L �/�� Title <br /> (Please PRINT or TYPE) / ' ) f ❑Corporation <br /> Address 1363J t�U y _ f . ,//Y J (t Phone Z(�f- <br /> Applicant Signature T Date oApplication+ <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> `/ _J_%L `',�, ( — 0000453 <br /> Facility ID CJ Program ecord ID �P/E_` �`� Assigned to PWS ID <br /> FA0000454 PR0270120 2765 9819-BENIAMINE WA0515730 <br /> Report#:7066 Application Printed:11/19/2020 <br />