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Joaquin County-Environmental Health Depai t PAYMENT 600 vlain Street-Stockton CA 9.5202-Phone: 209-ti,,,.-3420 RECEIVED APPLICATION SA"I JOAQuf �V I ENP ONMENTAL PERMIT TO OPERATE HETM q ROE MRF EMPLOYEE HOUSING OR LABOR CAMP ❑ New Camp [:]Conditional Permit ❑ Multiple fears(Permanent Housing Camps only) �nnual Permit for Calendar Year ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#' 0022183 *Additional Employees State ID#: 390158.55 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 NU Owner Address: 1532 SCENIC DR,MODESTO CA 95355 Owner Phone#:(209)604-5280 Community Facilities Provided by Camp: /i Community Kitchen? ❑ Yes No Nten: Number of Toiletsam 4 Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories '112,414 Housing Accommodations to be Utilized this Year: Occunancv Dates: Buildings Emnlovees / Dormitories from f / I / to��/��/�a�� Crop rICluS SF Dwellings from / / to / / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Not TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive 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 Bos and return this application. Fee Schedule 47 Permanent Camp Annual Permit Fe( S35.00+ Number of Employees $12.00 each=$ L ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ElPc tilanctd ruucndwcnt I-cc c2v.vii r Number of Auwtiunal Employees a!$IL.UU each= ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ / 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 Title 42& y,'/ ❑ Partnership (Please PRINT or TYPE) /, ❑Corporation Address ` �(J Gi'l s y Phone Applicant Signature Date of Application 1 Amount Paid Da ayment Payment Type Check/Receipt# Received By Account ID 0037333 Facility ID Program Record ID P/E Assigned to PWS ID FA0020798 PRO536203 2765 NCAN N/A 461 U11 e Regort#:26F}.rgt �K� a.3( 0,53 ation Printed:11/1/2012 ,