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PAYMENT oaquin County-Environmental Health Departs. <br /> RECEIVED 1868 E. Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> OCT 2 6 2015 <br /> SAN JOAQUIN COUNTY APPLICATION <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP !� <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year �• <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 /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000430 <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 /> t e-n!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 Camp: Community Kitchen? ❑ Yes No <br /> Men: Number of Toilets i'V A Number of Showers Number of Lavatories IVt� <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Emplovees / / 2A( ZZl <br /> / 3� aG Crop Dormitories from _/_/ _ p f <br /> SF Dwellings from —/—/-to—/ / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 36-5 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces <br /> 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 retum this application. <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fe( $35.00+ Number of Employees n $12.00 each=$ <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 cr $12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees (,$24.00 each=$ <br /> Fee must be submitted with Application 13// 60 <br /> TOTAL FEE DUE$ <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,S. chapter 3,Title 25, lifornia Code <br /> �ofRegulations. �n <br /> Applicant Name 1�/`/YL ay1/ � Title Ot/✓/�.,� ❑ Partnership <br /> (Please PRINT or TYPE) (+ ❑Corporatio <br /> AddressZr;p 3'6Phone <br /> Applicant Signature Date of Application WAEcounyb <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By <br /> 0037333 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0020798 PR0536203 2765 8987-SANGALANG N/A <br /> Report#:7066 Application Printed:10/13/2015 <br />