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San Joaquin County-Environmental Health Department PA <br /> . 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 ETrOENT <br /> APPLICATION NOV 15 2423 <br /> ENVIRONMENTAL HEALTH $AN JOAQUIN COU <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP H1=q�T 1RONMEN7A�TM <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <br /> H DEPARTMENT <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0029479 <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: THEALMONDS Location: 11250 MICKE GROVE RD, LODI <br /> Operator: KAUTZ,JOHN <br /> Mailing Address: 5252 BEAR CREEK RD, LODI CA 95240 Facility Phone#:(209)483-5395 <br /> Legal Owner: KAUTZ,JOHN New Owner? ❑Yes 0 No <br /> Owner Address: 5252 BEAR CREEK RD, LODI CA 95240 Owner Phone#:(209)334-4786 <br /> Community Facilities Provided by Camu: Community Kitchen? ❑ Yes No <br /> Men: Number of Toilets Number of Showers Number of Lavatories %t <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: ' <br /> Buildines Emulovees- Z'7 12— 3r <br /> Dormitories from,----/----/ / J"./� :- Crop s' _ <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 /> 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 <br /> [] Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$17.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$_ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Enveiope <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 of Regulations. <br /> Applicant Name Title .: 1- ❑Partnership <br /> (Please PRINT or TYPE) / -- e ❑ Corporation <br /> Address ( ;�,� fJ�i�j / _ `j`� Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 53 'l l ✓ rf--�— 0054203 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0027890 PR0548722 2765 9488-WONG N/A <br /> Report#:7066 Application Printed:11/1/2023 <br />