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Joaquin County-Environmental Health Depart t PAYMENT 600 E.Main Street-Stockton CA 95202-Phone: 209-4u8-3420 RECEIVED .intl 9 n �.— APPLICATION ENVIRONMENTAL HEALTII SAN JOA(IUIN COUNTY AL PERMIT TO OPERATE ENVIROM EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT ❑New Camp ❑Conditional Permit ❑ Multiple Years(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#: 39015855 EH ID#: 39000430 Please Note any Corrections or Changes in Facility/Operator Information directly on this form. 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 No Owner Address: 1532 SCENIC DR, MODESTO CA 95355 Owner Phone#:(209)604-5280 Community Faciliiies Provided by Cama: Community Kitchen? ❑ Yes LZ No (� IahMen: Number of Toilets Number of Showers I 1 NumbWer+oofL`avaoriesWomen: Number of Toilets Number of Showers U Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancv Dates: 1 �, � � � ��t� uddin s Emplovees o Qom( ` \ Dormitories J 1Trm /_/ to /_/ Crop 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: MI I/RV Spaces Note 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 Box and return this application. Fee Schedule Z,/ Permanent Camp Annual Permit Fei< $35 00+ Number of Employees _ a $12.00 each=$ �!/ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees a $12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees a $24.00--l- $ Fee must be submitted with Application TOTAL FEE DUE S ��J Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EIID Applicant agrees to all necessary inspections incident to issuance of a PERNIIT 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 raid Safety Code and Chapter 1,Subchapter 3,Title 25,Ct I.ornia Code of Regulations. t pr Applicant Name Title \ rtners ip (Please PR/NT or TYPE) Corpor t on Address 3� Phone �� \ O t!— Applicant Signature Date of Application t Amount Paid Date of P.74n Payment Type Check/ eceipt# Received By Account ID 0037333 Facility ID Program Record ID �P//E (� Assigned to PWS ID FA0020798 PR0536203 2765 nnna1 -TURKATTE N/A Date Report#:7066.rpt t 3t Z ..,�5I Application Printed:10/2512011