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14EC cMEN T San Joaquin County-Environmental Health Department EI V E p 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 SEP 14 2Q?J- APPLICATION EN tRO WUIN COUNTY ENVIRONMENTAL ERMIO HEALTH &1EA(_TH DEARTNAENT EMPLOYEE HOUSING OR LABOR CAMP New Camp [-]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑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#: i EH ID#: Please Note anv 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 LegalOwner: Champ Patel New Owner? E]Yes N No owner Address: 4219 Waterloo Stockton CA owner Phone#: 209-931-3131 Communitv 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 Houcine Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories 1 30 from 4_/25/ 21 to 1 /15/22 Crop Tree Fruit SF Dwellings from / / to_/_/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 2550 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/kV Spaces Note TOTALS30 Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive 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. Fee Schedule ® Permanent Camp Annual Permit Fee S50.00+ 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 $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 456 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) ® oration Address 312 E Mill Suite 202 Santa,Maria, CA 93454 Phone 805 357 Co1322 Applicant Signature Date of Application 3/12/2021 Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID eL`-�u - / , s`oTg Facility ID Program RecordID Pl/EtP Assigned !t� PWS ID N/A2//, 0� �S� 72DO Report#:7066 Application Printed:3/10/2021