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San Joaquin County-Environmental Health Department <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year 2023 <br /> ®Amended P—nit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#: 0026139 <br /> *Additional Employees <br /> State ID#: <br /> EH ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: FRESH HARVEST INC Location: 4219 WATERLOO RD,STOCKTON <br /> Operator: GURROLA,ADRIAN <br /> Mailing Address: 101 E MAIN ST,HEBER CA 92249 Facility Phone#:(760)996-2252 <br /> Legal Owner: STEVE SCARONI New owner? ❑Yes ® No <br /> Owner Address: 101 E MAIN ST,HEBER CA 92249 Owner Phone#:(760)996-2252 <br /> Community Facilities Provided by Camp: Community Kitchen 7 ❑ Yes ❑X No <br /> Men: Number of Toilets 49 Number of Showers 49 Number of Lavatories 49 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occunancv Dates: <br /> Buildings Employees <br /> Dormitories 3 212 from 4/26/2023 to 10/30 /2023 Crop Garlic <br /> SF Dwellings from /_/ to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces <br /> Note <br /> IY)I A LS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> 212 Require a PUBLIC WATER SYSTEM Permit <br /> ❑Lltactivc <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 Fee $50.00+ Number of Employees (a3$17.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> a❑ Permanent Amendment Fee S25.00+ Number of Additional Employees 212 @$17.00 each=$ 3,604.00 <br /> ❑ Late Application Fee S100.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ 3,629.00 <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,California Code ofRegalations. <br /> Applicant Name Adrian Gurrola Title Housing Coordinator ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address 101 E Main St,Heber,CA 92249 Phone 760-9996-2252 <br /> Applicant Signature Date of Application ✓ A2�iZ3 <br /> Amount Paid Date of Payment Payment Type Ch eceipt# Received By Account ID <br /> 0046122 <br /> Facility ID Program Record ID —!`P/E L1J0 Assigned to PWS ID <br /> FA0024661 PR0543451 2755 3611-GIRARDI N/A <br /> Report#:7066 Application Printed:3/29/2023 <br />