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RECEIVED I Joaquin County-Environmental Health Depart, c 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-34207' r 2J l tNVIRONMENTAL HEALTH APPLICATION PERMIT/SERVICES ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar Year 2 01 8 ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#• 0022183 *Additional Employees State ID#: 39-15855-EH Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000430 Site Name: RIPON FARMS 39-430 Location: 23531 S JACK TONE RD, RIPON Operator: HOGAN,THOMAS P Mailing Address: 1532 SCENIC DR,MODESTO CA 95355 Facility Phone#:(209)492-9335 Legal Owner: HOGAN,THOMAS P New Owner? ❑Yes JJ No Owner Address: 1532 SCENIC DR,MODESTO CA 95355 Owner Phone#:(209)604-5280 Community Facilities Provided by Camp Community Kitchen? ❑ Yes ® No Men: Number of Toilets n/a Number of Showers n/a Number of Lavatories n/a Women: Number of Toilets n/a Number of Showers n/a Number of Lavatories n/a Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Emolovees Dormitories from01 /01 2018)-12/31/20-18 CmP Varies SF Dwellings from _/ / to_/ / Crop Apartments 8 8 Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3 6 5 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 0 MH/RV Spaces Note TOTALS ® ® Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive m psi rl a o t: 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 8 @$15.00 each=$ 120. 00 ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ fate Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 170. 00 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 'Phomas Hogan Title Uwner ❑ Partnership (Please PRINT or TYPE) ❑Corporation Address 1207 13th St. uite Modesto CA 95354Phone (209) 492-9335 Applicant Signature Date of Application . 11/3/2017 Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 0037333 Facility ID Program Record ID P/E Assigned to PWS ID FA0020798 PR0536203 2765 8987-SANGALANG N/A Report#:7066 Application Printed:10/23/2017