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PAYMENT San Joaquin County-Environmental Health Department RECEIVED 1868 E Hazelton Ave-Stockton CA 95205-Phone: 209-468-3420 APPLICATION ENVIRONMENTAL.H LA L f H PERMIT TO OPERATE SAN JOAQUIN COUNTY EMPLOYEE HOUSING OR LABOR CAMP y{,�ppEe�'NVVTMlRr�O�N,�MMEppNTAL ❑New Camp []Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit for t!dfit'TITA'S l� ,DIK _ TMENT ❑ Amended Permit: "Change of Operator "Change of Owner "Change of Operator Address "Change of Owner.Address "Additional Employees State Ill#: 3q•l S''7 o 9- EN Please Note any Corrections or Changes in Facilih/Operator Information directly on this form. Site Name: P\\1TIA PROPERTIES LTD 39-423 Location: 4780 L FRENION'IST S"TOC KTON Operator: PANE'L.LAPROPERTIES LTD 39-423 Mailing;Address: PO BOX 5010,STOCKTON CA 9520.5 Facility Phone#: (209)943-5000 Legal Owner: PANELLA PROPERTIES L'I'D New Owner? ❑ Yes JR No Owner Address: PO BOX 5010,STOCKTON CA 95205 Owner Phone#: (209)981-1531 Ismail Community Facilities Provided by(,a in p: ommunity Kitchen? ❑ Yes g[ No Men: Numberof Toilets Z, Number of Showers 3 Number of Lavatories 3 Women: Number of Toilets Number of Showers Number of Lavatories housing Accommodations to be Utilized this Year: Occuuancv Dates: Dormitories Buildines Employees �A from �/ � / 2�to / 39 2V Crop � SF Dwellings from / / to / / Crop Apartments p Owner Owned MH/RV 'Total Number of Days to be used this Calendar Year: 190 0 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: M/A MH/RV Spaces — �Z 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: bio"ICr 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 $54.00+ Number of Employees Z @$17.00 each= ❑ Transferof Ownership $25.00=`ti_` ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees !rb$17.00 each=$_ ❑ Late Application Fee $108.00+ Number of Employees I�D,$34.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed Envelope MAKE CHECKS PAYABLE to END 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 Safeg;Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name !&013199T RM4E LIL,A Title QV,(06fL ❑Partnership (Please PRINTor TYPE) I( QQ ,,/ Corporation Address QO I�i_ yF �t�, �VON� ST. CA —1S2�J Phone .Applicant Signature Date of Application{� Amount Paid Date of Pa en Payment Type Che Receipt# Received By Ck 'S X77 Facility ID Program Record ID P/E Assigned to PWS ID I A0016255 R0524211 2755 'astina Thanuuavongsa Report#:7067.rpt _ m�