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PAYMENT San Joaquin County-Environmental Ilealth Department RECEIVED 1868 E Hazelton Ave-Stockton CA 9i205-Phone: 209468-3420 MAR 2 ? D� APPLICATION ENVI RMI RONE OPERATE HEALTH SAN JOAQUIN COUNTY EMPLOYEE HOUSING OR LABOR CAMP HEALTHENV' D NMENTgL ❑Ne,r Camp Conditional Permit E�TH�EPgRT�ENT ❑ El Years(Permanent Housing Camps only) ® Annual Permit for Calendar Year 2UZb� ❑ Amended Permit: "Change of Operator "Change of Owner "Change of Operator Address "Change of Owner Address "Additional Employees State ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on this form. Site Name: FRANK N ROCHA DAIRY LP#1 39-345 Location: 23243 E LONE TREE RD ESCALON Operator: FRANK N ROCHA DAIRY LP#1 39-345 Mailing AddreZ: E LONE TREE RD,ESCALON CA 95320 Facility Phone#: (244)8444444 Legal Owner: ROCHA,FRANK N AND KATHY,SILVA,JOHNNY,& New Owner? ❑ Yes ❑ No MEGAN Owner Address% 2" •:LONE TREE RD,ESCALON CA 95320 Owner Phone#: 10�V Zil math Communitv Facilities Provided by Camn: Community Kitchen? ❑ Yes W No Men: NumberofToilets tO NumberofShowers 0 Number of Lavatories O Women: Number ofToilets NumberofShowers p Number of Lavatories Housing Accommodations to be Utilized this Year: Occupanch Dates: Buildings Eninlovees Dormitories from t /1.6 to 2 / l 1 z10 Crop SF Dwellings from / / to / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3�� Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces 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: 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 $54.00+ Number of Employees _ 0 @$17.00 each=$ 3tei ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ F] Late Application Fee $108.00+ Number of Employees @$34.00 each=$ Fee must be submitted with Application TOTAL FEE DUE !�, Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed Envelope MAKE CHECKS PAYABLE toEHD 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 Heald[and safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name Sp TitleC� /C ❑Partnership (Please PRINT or TYPE) ❑Corporation Address 232-4 DA UceaNmy,, (� ", 1532 O Phone L-wq) 6SZ-' ACtT9 Applicant Signature Date of Application Zy� Amount Paid Date of Payment Payment Type Check/Receipt# Received By Facility ID Program R=ID PIE Assigned to PWS ID FAD003360 R0515635 765 Rena LeRoy Report#:7067.rpt