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DAY <br /> oaquin County-Environmental Health Depart I r1%1 T <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 RECEIVED <br /> ►Intl D ') �. <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY <br /> PERMIT TO OPERATE ENVIROMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) nnual Permit for Calendar Year v v l 2 <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID N: 0022183 <br /> *Additional Employees <br /> State ID#: 39015855 <br /> EH ID#: 39000430 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this forn7. <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 /> Owner Address: 1532 SCENIC DR, MODESTO CA 95355 Owner Phone 41-""9%F04-5280 <br /> Community Faciiiiies Provided b Cam 1 Community Kitchen? ❑ Yes N� 1, <br /> Men: Number of Toilets Number of Showers _ _ Nuns ger of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancv Dates: <br /> Emplovees (} ` \( (' <br /> Dormitories \-\�'from /�/ —to Z /3!'/ �Z Crop <br /> SF Dwellings �I from _/_/ to_/ / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 6 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <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 /> Fee Schedule if 9 '� )3 <br /> Annual Permanent Camp Permit Fe( $35.00+ Number of Employees _ @$12.00 each=$_ / <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 @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.0( <br /> Fee must be submitted with Application -- <br /> TOTAL FEE DUE$ <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,Subchapter 3,Title 25,Ca ifornia Corte of Regulations. ` ' V <br /> Applicant Name -514 Title ��\ Hers ip <br /> (Please PRINT or TYPE) CorpOratjoYtl <br /> (A�Address Phone <br /> Applicant Signature �' ' 1�7 Date of Application <br /> G <br /> Amount Paid Date of Pa ent Payment Type C eckl eceipt# Received By Account ID <br /> 0037333 <br /> l`Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0020798 PRO536203 2765 nnnd 1 -TURKATTE N/A <br /> c-7rZ W0AWDated 31 IZ <br /> Report#:706 .rpt Application Printed:10/25/2011 <br />