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PAYMENT <br /> ' <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 APR 0 5 2023 <br /> SAN JOAQUIN COUNTY <br /> APPLICATION ENVIRONMENTAL <br /> ENVIRONMENTAL HEALTH HEALTH DEPARTMENT <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 Permit: "Change of Operator 'Change of Owner <br /> "Change of Operator Address "Change of Owner Address Permit ID tl: 0026139 <br /> "Additional Employees <br /> State ID a: <br /> EH[D M. <br /> Please Note any Corrections or Changes In Facilitp Operator Information dimcdp on thisJorrn. <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#:(780)996-2252 <br /> Legal Owner: STEVE SCARONI New Owner? ❑Yes ® ?.0 <br /> Owner Address: 101 E MAIN ST,HEBER CA 92249 Owner Phone#:(760)996-2252 <br /> Communitv Facilities Provided by Comp: Community Kitchen 7 ❑ Yes ® No <br /> Men: Number of Toilets 5 Number of Showers 5 Number of Lavatories S <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> HooRine Accommodations to he Utilized this Year: Occunancv Dates: <br /> Buildiri Emnlavecs <br /> Dormitories 1 25 from _/X/2023 to 10/30 12023 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 Note <br /> TOTALSCamps occupied by 25 or more Employees for 60 or more days in a year <br /> 25 Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> Imnartimil 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 Boa and return this application. <br /> Fee Schedule <br /> X❑ Permanent Camp Annual Permit Fee $5000+ Number of Employees 25 @$17.00 each=S $425.00 <br /> ❑ Transfer of Ownership $25.00-S <br /> ❑ Permanent Amendment Fee $2500+ Number of Additional Employees @ S17.00 each=S <br /> ❑ Late Application Fee S10000+ Number of Employees Re 534.00 each=S <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE S 475.00 <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 previsions of the EMPLOYEE HOUSING ACT. Chapter 1, Part 1, Division 13 of the California Health <br /> and Safery Code and Chapter 1,Subchapter 3,Title 25,California Code ofRegtrlations. <br /> Applicant Name Adrian Gurrola Title HOUsina Coordinator ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address 101 E M5' St .He er,CA 92249 Phone 760-996-2252 <br /> Applicant Signature t Il;ttr of Application �3 <br /> Amount Paid Date of Payment Payment Type Che eceipt# Rer.eived By Account ID <br /> AA- 6 r 20 uo t( 1 ^ 0048122 <br /> Facility ID Program Record ID PIE �[ Assigned to PWS ID <br /> FA0024661 PR0543451 2755 3611 -GIRARD! N/A <br /> Report# 7066 Application Printed:3/29/2023 <br />