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San Joaquin County-Environmental Health Department PAYMENT 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 RECEIVED APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: State ID#: 99-el 6,YSS-EN Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: C( 3r) Site Name: AV — 3c7 Location: `Z� d r r Operator: JACAAWA 1A Mailing Address: Z� t �� C di Phone#: Legal Owner: ' New Owner? ❑Yes ❑ No Owner Address: gJhr. S' Phone#: Z' Community Facilities Provided by Camp: /Community Kitchen? E] Yes Not Men: Number of Toilets (,Iht 1 ^' Q 1� 6Number of Showers Number of Lavatories lal-I 1/Cy' ��t Women: Number of Toilets / , Number of Showers Number of Lavatories 44 Housine Accommodations to be Utilized this Year: 2D/ Occupancy Dates: P�Oik4wm Buildings Em to ee Dormitories / from i! / I to /-3 Crop SF Dwellings U1 from _/_/ to Crop 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 Note TOTALSCamps 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 Permanent Camp Annual Permit Fee $35.00+ Number of Employees @$12.00 each=$ ❑ Orchard Camp Permit Fee $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ Fee must be submitted with Application TvTAL FEE vUE$ � �• 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,C lifornia Code of Regulations. Applicant Name S' T Title ©t✓l�r ❑Partnership (Please PRINT or TYPE) V ❑Corporation Address s Se-eyly V Pr 111 &IS6. a /gl�one &q- 2- -�� Applicant Signature ✓L' Date of Application .3 Amount Paid Date of Paymev Payment Type Check/RecaWt# Received By Account ID /5- Facility ID Program Record ID PIE Assigned to PWS ID RZ:7067.rpt`, rs �� G� 1`��/ 7 �Ct Application Printed:3/3/2011