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PAYMEN-f <br /> RECEIVED RECEIVED <br /> San Joaquin County-Environmental Health Department <br /> DEC 15 2011 2017 <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> SAN tQUN CAulm <br /> HEALTH DEPARTMENT trtylNMENTAL HEALTH <br /> hCU <br /> APPLICATION PERMIT/SERMFS <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit E] Multiple Years(Permanent Housing Camps only) <br /> ®Annual Permit for Calendar Year 2 0 18 <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID N: 0022183 <br /> *Additional Employees State ID M 3945855-EH <br /> EH ID#: 39000430 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: RIPON FARMS 39-430 Location: 23531 S JACK TONE RD, RIPON <br /> Operator: HOGAN,THOMAS P <br /> Mailing Address: 1532 SCENIC DR,MODESTO CA 95355 I�acilitN Phone 4:(209)492-9335 <br /> Legal Owner: HOGAN,THOMAS P New Owner? ❑Yes ❑ No <br /> Owner Address: 1532 SCENIC DR,MODESTO CA 95355 Owner Phone#:(209)604-5280 <br /> Community Facilities Provided by Cama: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets n/a Number of Showers n/a Number of Lavatories n/a <br /> Women: Number of Toilets n/ a Number of Showers n/a Number of Lavatories n/a <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Emglovees <br /> Dormitories from01 /01 /.2018)-12/31/22018 Crop varies <br /> SF Dwellings from / / to_/ / Crop <br /> Apartments 13 $ <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 365 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 0 <br /> MH/RV Spaces Note <br /> Camps occupied by 25 or more Employees for 60 or more days in a year <br /> TOTALS L-•J ® Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive l-J <br /> 1 m o octant: 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 <br /> ® Permanent Camp Annual Permit Fee $50-00+ Number of Employees 8 @$15.00 each=$ 12 0 . 0 0 <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$ 170 . 00 <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 /> Applicant Name Thomas Hogan <br /> Title Owner ❑Partnership <br /> [1 Corporation <br /> (Please PRINT or TYPE) <br /> Address 1207 13th St. �'uite Modesto LA 95354 Phone �209j 492-9335 <br /> Date of Application 11/3/2 017 <br /> Applicant Signature <br /> Amount Paid Date of Payment Payment Type Chec ceipt# t Rved By Account ID <br /> 0037333 <br /> --7 <br /> I 6 PIE (� Assigned to PWS ID <br /> Facility ID Program Record ID <br /> FA0020798 PR0536203 2765 8987-SANGALANG N/A <br />