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San Joaquin County-Environmental Health Department 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP q.� El New Camp E]Conditional Permit E] Multiple Years(Pemanent Housing Camps only) ER Annual Permit for Calendar Year to ZA i ❑Amended Permit: *Change of Operator *Chong¢of Owner *Change of Operator Address *Change of Owner Address Permit ID#: 0007065 *Additional Employees State H)#: 39-0322-EH Please Note any Corrections or Changes to Facility/Operator Information directly on this form. EH iD#: 39000322 Site Name: VAN GRONINGEN&SONS 39-322 Location: 14225 E FRENCH CAMP RD, RIPON Operator: VAN GRONINGEN,BOB Mailing Address: 15100 S JACKTONE RD,MANTECA CA 95336 Facility Phone#:(209)982-5248 Legal Owner: VAN GRONINGEN&SONS New Owner? ❑Yes No Owner Address: 15100 S JACKTONE RD,MANTECA CA 95336 Owner Phone 4:(209)982-5248Ext: Community Facilities Provided by Comm Community Kitchen Yes ❑ No Men: Number of Toilets Number of Showers 3 Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories i Housine Accommodations to be Utilized this Year: Occupancy Dates: uildh s Emnlovees Dormitories �_ t� from �/�qq/f/ Zq to LZ/3 1 /A Crop SF Dwellings from _/_/ to_/ / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Note TOTALS 1 ) Z t/ Camps occupied by 25 or more Employees for 60 or more days in a year 9 Require a PUBLIC WATER SYSTEM Permit ❑Inactive Lnoortant: 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 P'ce Schedule Q{,11 y®� Permanent Camp Annual Permit Fec $50.00+ Number of Employees A "1 _ @$17.00 each=$ r ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$34.00 each=$ Fee must be submitted with Application �--p TOTAL FEE DUE$ i Remit TOTAL FEaas/as ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EIID Applieant 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 Safety Code and Chapter 1,Subchapter 3,Title 25,California Corte of Regulations. Applicant Name S(xy"}1 wo Title �a. q AP&W El Partnershipi (Please PRINT or TYPE) /�, ` [Corporation Address _ 151 WO Sy0, k i I�..t_Y (� � 1A 05,�1(e Phon0A91H1fa--9_{Q.� Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID N,i pi0� y 2� 0006485 Facility ID Program Record ID PIE Assigned to PWS ID FAD005765 PRO503285 2765 0039-GOODERHAM WA0515718 i Report#:7066 Application Printed:11/1/2023