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PPYMEN <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 APR 0 4 2024 <br /> SAN JOAQUIN COUNTY <br /> APPLICATION ENVIRONMENTAL <br /> ENVIRONME NTAL HEALTH HEALTH DEPARTMENT,' <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP qq.� <br /> ❑New Camp []Conditional Permit ❑ Multiple Years(Permancot Housing Camps only) Anneal Permit for Calendar Year L9 Z� <br /> ❑Amended Permit- *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID 0: 0007065 <br /> *Additional Employees <br /> State ID#: 39-0322-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000322 <br /> Site Name: VAN GRONINGEN$SONS 39-322 Location: 14225 E FRENCH CAMP RD,RIPON <br /> Operator: VAN GRONINGEN,BOB <br /> Mailing Address: 15100 S JACKTONE RD,MANTECA CA 95336 Facility Phone#:(209)982-5248 <br /> Legal Owner. VAN GRONINGEN&SONS New Owner? ❑Yes Ja No <br /> Owner Address: 15100 S JACKTONE RD,MANTECA CA 95336 Owner Phone 4:(209)982-5248Ext: <br /> Community Facilities Provided by Camp: Community Kitchen? Yes ❑ No <br /> Men: Number of Toilets Number of Showers 3 Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> i <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buntlines Employees <br /> Dormitories - f�Y from I /at/ IN to I2/31/1 Crop <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 � Z� 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 /> Impgrtan: 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 /> Fcc Schedule <br /> Permanent Camp Annual Permit Fec $50.00+ Number of Employees IAq (�_ @$17.00 each=$ l L9Q <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 FE E DUE$ / ,V V <br /> Remit TOTAL FED4 CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to E11D <br /> Applicant agrees to al]necessary inspections Incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated i <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Ifealah I <br /> and Safety Code and Chapter 1,Subchapter 3, itle 25,California Corte of Regulations. <br /> Applicant Name (� <br /> PP _c�(�}�yVp tx � Title �al �a�((�� ❑Partnership <br /> (Pleese PRWT or TYPE) ,n ` [Corporation <br /> Address 1 S1 C o .S �Oul,�e��a,.e_1 Ut /Ah P Phone �n9>q,t.=9�a�� <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type W&Wck/Receipt# Received By. Account ID <br /> qq'i�Q L/ 1VISA 2 0006485 <br /> �! 7 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FAD005765 PRO503285 2765 0039-GOODERHAM WA0515718 <br /> t <br /> i <br /> Report it.7066 Application Printed:11/1/2023 <br />