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San Joaquin County-Environmental Health Department PAYMENT 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 RECEIVED MAR 2 a APPLICATION SAN JOAQUIN COON7Y, ENVIRONMENTAL HEALTH FJENI ON ENTAL PERMIT TO OPERATE AWIE1, EMPLOYEE HOUSING OR LABOR CAMP ®New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar Year 2025 ❑Amended Permit: 'Change of Operator *Change of Owner -Change of Operator Address *Change of Owner Address Permit ID#• *Additional Employees State ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on/his form. EH ID#: Site Name: WATERLOO INN Location: 3951 BUDWEISER CT,STOCKTON Operator: FRESH HARVEST,INC. Mailing Address: 101 E MAIN ST,HEBER CA 92249 Facility Phone#:(760)791-5114 Legal Owner: KHUSAL,MEERAN New Owner? ❑Yes ® No Owner Address: 101 E MAIN ST,HEBER CA 92249 Owner Phone#:(760)996-2252 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes © No Men: Number of Toilets 40 Number of Showers 40 Number of Lavatories 40 Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildines Employees Dormitories 1 160 from 05/01/2025 to 12/ 31/2025 Crop Garlic 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 TOTALSCamps occupied by 25 or more Employees for 60 or more days in a year 160 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 X❑ Permanent Camp Annual Permit Fee S50.00+ Number of Employees 160 (a,$17.00 each=$ $2720.00 ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees (a,$17.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees $34.00 each=$ Fee must be submitted with Application TOTAL FEE DUE S $2772.00 Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD 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 Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name SALOME RAMIREZ Title H2A MANAGER ❑Partnership (Please PRINT or TYPE) ®Corporation Address 101 E MAIN ST,HEBER,CA 92249 Phone 760-791-5114 Applicant Signature ---- - Date of Application 03/10/2025 Amount Paid Date 0 Payment Payment Type Check/Receipt# Received By Account ID a 77a.b � z5 C� 21S��S• Facility ID Program Record ID PIE Assigned to PWS ID FA0024661 Report It 7066 Application Printed:3129/2023