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, MENr San Joaquin County-Environmental Health Department RECEI V ED 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 SEP i 4 2021 N JOA C APPLICATION t ENVIRO COUNTY NM ENVIRONMENTAL R IT OPERE LTH HEALTH DE gRTMENT EMPLOYEE HOUSING OR LABOR CAMP New Camp ❑Conditional Permit ❑ Multiple Years(Permancnt Housing Camps onl.) ❑Annual Permit for Calendar Year ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#• *Additional Employees State ID#: EH ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on this form. Site Name: Clarion Inn Location: 4219 Waterloo,Stockton, CA Operator: Smith Packing, Inc. Mailing Address: 312 E Mill Suite 202, Santa Maria CA 93454 Facility Phone#: 8053571322 Legal Owner: Champ Patel New Owner? ❑Yes No Owner Address: 4219 Waterloo Stockton CA o,yner Phone#: 209-931-3131 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes No Men: Number of Toilets 8 Number of Showers 8 Number of Lavatories 8 Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildines Emolovices Dormitories 1 30 from 4_/25/ 21 to-1 /15/22 cmp Tree Fruit SF Dwellings from _/_/ to / / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 250 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 30 Require a PUBLIC WATER SYSTEM Permit ❑Inactive Imuortant: 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 Employees 30 @$15.00 each=$ 450 ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee S100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 4 JlJ Cly 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 Vernon Smith Title Director ❑Partnership (Please PRINT or TYPE) ®Co oration Address 312 E Mill Suite 202 Santa Maria, CA 93454 Phone 805 357 1322 Applicant Signature Date of Application 3/12/2021 Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID S�°fig Facility ID Program Record ID PIE Assigned t PWS ID 2 75 61f77�o z7�.S R83 N/A Report#:7066 Application Printed:3/10/2021