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Y <br /> PAYMENT S aquin County-Environmental Health Departr, <br /> PAYME T 1868 E.t,azelton Avenue-Stockton CA 95205-Phone: 209-4o8-3420 <br /> NECEIVAPPLICATION <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> ENVIRONMENTAL PERMIT TO OPERATE <br /> HEALTH DEPARTMENT EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar Year 2 0 17 <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0022183 <br /> *Additional Employees <br /> State ID#: 39-15855-EH <br /> EH ID#: 39000430 <br /> Please Note any Corrections or Changes in FacilitviOperator 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 Facility Phone#:(209)492-9335 <br /> Legal Owner: HOGAN,THOMAS P New Owner? ❑Yes EJ No <br /> Owner Address: 1532 SCENIC DR, MODESTO CA 95355 Owner Phone#:(209)604-5280 <br /> Community Facilities Provided by Camp: 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 Employees <br /> Dormitories from 01 /01/2 017to 12 /31/2017 Crop Varies <br /> SF Dwellings from / / to / / Crop <br /> Apartments 8 8 <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 /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> ® ® Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> 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. <br /> q-,$.0'0 Fee Schedule 1.5, --r-L) <br /> ❑ Permanent Camp Annual Permit Fet $3�,X+ Number of Employees 8 @$17r,K each=$ 120 . 00 <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application TOTAL FEE DUE$1 6 5 . 0 0 <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,Cali Code f e uI tions. <br /> Applicant Name Thomas Hogan -zlTitle Owner ❑ Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address 1207 13th St. , Suite 1 , Modesto, CA 95354 Phone (209) 492-9335 <br /> Applicant Signature Date of Application 10/30/16 <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> S ItLl-%J/6 }� 0037333 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0020798 PR0536203 2765 8987-SANGALANG N/A <br /> Report#:7066 Application Printed:10/14/2016 <br />