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San Joaquin County-Environmental Health Department PAYMENT 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 RECEIVED APPLICATION SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ENVIRONMENTAL PERMIT TO OPERATE HEALTH DEPARTMENT EMPLOYEE HOUSING OR LABOR CAMP ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) 1A Annual Permit for Calendar Year 2-024 ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#• 0016511 *Additional Employees State ID#: 39-15709-EH Please Note any Corrections or Changes in Facility/Operator Information directly on this form EH H)#: 39000423 Site Name: PANELLA PROPERTIES LTD 39-423 Location: 4780 E FREMONT ST,STOCKTON Operator: PANELLA, ROBERT Mailing Address: PO BOX 5010,STOCKTON CA 95205 Facility Phone#:(209)943-5000 Legal Owner: PAN ELLA PROPERTIES LTD New Owner? ❑Yes No Owner Address: PO BOX 5010,STOCKTON CA 95205 Owner Phone#:(209)943-5000 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ® No Men: Number of Toilets Number of Showers 3 Number of Lavatories 3 Women: Number of Toilets ( Number of Showers It Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates:' Buildint=s Employees / Dormitories from __!6_/_L 14to AL 1 114_ Crop 1`�6 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 — to TOTALS r------- 12 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 $50.00+ Number of Employees @$17.00 each=$ 2 Sy 60 ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ ❑ I.ate Application Fee $100.00+ Number of Employees @$34.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ (Io 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 4 ,0 P; ,+ /rite1l# Title Qf,(>/f Q� ElPartnership (Please PRINT or TYPE) 14 Corporation Address k /S Phone 1,)!? 9SF3 �,r Applicant Signature Ifl117 Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID /J- QT'S /S_ FS 0028428 Facility ID Program Record ID ` P/E D Assigned to�((� PWS ID FA0016255 PR0524211 2755 9834-SUSZYCKI WA0515719 Report#:7066 �� ( � I O Application Printed:11/1/2023