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oaquin County-Environmental Health Depar_ Pry c c yM 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 C` V N 7 IA 4 APPLICATION SAN JQ 022 ENVIRONMENTAL HEALTH NEALT/RO UM�CCUNT PERMIT TO OPERATE N EMPLOYEE HOUSING OR LABOR CAMP N�EPARTM Y ❑New Camp E]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year �� 2.. mAmended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit 1D#• 0028271 *Additional Employees State ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: Site Name: SMITH PACKING-WATERLOO FACILITY Location: 4219 E WATERLOO RD,STOCKTON Operator: HERNANDEZ, EMANUEL Mailing Address: 312 E MILL STE 202,SANTA MARIA CA 93454 Facility Phone#:(805)249-7171 II Legal Owner: SMITH,VERNON New Owner? ❑Yes © No Owner Address: 312 E MILL STE 202, SANTA MARIA CA 93454 Owner Phone#:(805)357-1322 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes No Men: Number of Toilets 10 Number of Showers b Number of Lavatories `10 Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildines Em lovees Dormitories /[7 V O from 3 /1 / 2 Z to1 ti/ / �'L Crop 't t L v r� i SF Dwellings from —/—/—to / / Crop Apartments Owner Owned ME/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Nota TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive Im o�rtant: 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 _ ® Permanent Camp Annual Permit Fee $50.00+ Number of I niployees 10 @$15.00 each=$ C% " ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ C(/ 9 D Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed 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 U try��tn S�'t�� Title b A Partnership (Please PRINT or TYPE) I l� ®Corporation Address Ji l 2, L •' t 1\ Q 2b'L t CI fnr l '` I(I Phone Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 0?—) '12512.7— (4-k t�29ll 0051048 Facility ID Program Record ID PIE / Assigned to PWS ID FA0026784 PR0547200 2765 9834-SUSZYCKI N/A Report#:7066 Application Printed:12/2/2021