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oaquin County-Environmental Health Departi, PAYMENT <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 RECEIVED <br /> APPLICATION <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH <br /> ENVIRONMENTAL <br /> PERMIT TO OPERATE HFALTH DEPARTMENT <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 /> Legal Owner: HOGAN,THOMAS P New Owner? ❑Yes ® No <br /> C::ner 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/_2014o 12/31/2014 Crop Various <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 <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 return this application. <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fet $35.00+ Number of Employees 8 @$12.00 each=$ 96 . 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 <br /> TOTAL FEE DUE$ 131 . 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 and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name Thomas Hogan Title Owner ❑ Partnership <br /> (Please PRINT or TYPE) <br /> Corporation <br /> Address 1207 13th St. , Ste , Modesto, CA 95354 Phone (209) 604—,,5,280 <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> ✓: � I��� / /L 0037333 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0020798 PR0536203 2765 6219-DUNCAN N/A <br /> Repot#:7066 Application Printed:10/17/2013 <br />