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SAN JOAQUIN COUNTY a PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 K WEBER AVENUE • THIRD FLOOR • STOCKTON CA 95202 • Phone: 209/468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑Annual Permit For Calendar Year ❑Ascended Permit ❑Multiple Yeah(Permanent Housing Camps ano) lamp ate A roved • Change of Operator •Change of Owner ate Mailed: • Change of Operator Address • Change of Owner Address ermit# • Additional Employees ID# Please Note any Corrections or Ch4nga In Facllli/U erator Owner Information directly on this form Site Name: TOLEDO 01,JOHN&SON 31-3 3 LI Location: 2622 N ELLIOTT RD Operator: TOLEDO#1,JOHN&SON Mailing Address: 26280 N ELLIOTT RD,GALT CA 95632 Facility Phone#: 209-369-9226 Legal Owner: TOLEDO,TONY&JOHN ea Owner ❑Yes 4 No Owner Address: 26280 N ELLIOTT RD,GALT CA 95632 Owner Phone M 209-369-9226 Community Facilities Provided by Camp: Community Kitchen: ❑Yes Z No Men: Number of Toilets Number of Showers Number of Lavatories Women:Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: a n Employees >� I1� Dormitories: CMner Owned MH/RV — SF Dwellings Owner Owned RR Can Apartments MH/RV Spaces TOTAL of Both COLUMNS Occupancy Dates: from / / to / / Crop Total Number or Days to be rased this Calendar Year from / / to / / Crop Total Days Occupied by 15 o►asm Employees —— ——— — Note: Camps occupied by 25 or more empiayres for 60 or more days a year rvqui re a PaMe Water System Perm t ❑ Inactive .. In order to protect your land use status,Vcamp will not be used this year but Is lrtusdeelfbr as*in Meiltwn.Check this Box and return tlus dr ucatim Fee Schedule vt f d t1 Permanent Camp Annual Permit$35.00+Number or Employees 16 $12.00 each—S i 1 _ �� ❑ Orchard Camp Permit Fee=$95.00=S ►mil / ❑ Transfer of Ownership=$20.00—S lG �OJ 441- '),_ ❑ Permit Amendment=$20.00+Number or Additional Employees @$12.00 each=$ ❑ Late Application Fee$70.00+Number or Employees @$24.00 each=$ _ Fee must be submitted with Application TOTAL FEE DUE: K— REMTI TOTAL FEE AS CALCULATED ABOVE IN THE RNCLO.WD self-addressed ENVELOPE. AfA)W CHE00PAYARLETO: PHSX111) Applicant agrees to all necessary Inspections Incident to issuance of a PERMrr TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained In accordance with the applicable provisions of the EMPLOYEE HOUSINO ACT,Chapter 1,Part 1,Division 13 or the Heath and Safety Code and Chapter 1,Subebepter 3,Title 25,California Code ofRegUlatlons. Applicant Name _ _ 6 (�` Tide�l�t 1 r7+e K .H Partnership ❑Corporation (Pleas•PRINT or TYPL) Address l Phone Applicant Signature /Y _ r7� Date of Application Il =Z — Program Recor4 200134 Facnky ID# 003408 Account ID# 0003824 Arrant Paid Date of Payment en T m ed a t# Riecelved to Ernpioyee B — Acd R ---- Fat ID:9j u PR•: PWS ID*. PIE;�.�,--, 02 77s