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Joaquin County-Environmental Health Depar, <br /> 600 C.Main Street-Stockton CA 95202-Phone: 209-4620 RECD W <br /> APPLICATION <br /> ENVIRONMENTAL HEALTHS JOAOVIt4 cool"", <br /> MEWAL <br /> PERMIT TO OPERATE lNARDEPAR1mENT <br /> EMPLOYEE HOUSING OR LABOR CAMP H <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) fAnnual Permit for Calendar Year 2-_ <br /> ❑Amended Permit: *Change of Operator *Change of Owner 7� <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0010973 <br /> *Additional Employees State ID#• 39015750 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000333 <br /> Site Name: TEIXEIRA, MANUEL DAIRY#1 (39-333) Location: 11493 N DAVIS RD,LODI <br /> Operator: TEIXEIRA,MANUEL&ROSA <br /> Mailing Address: 11401 N DAVIS RD,LODI CA 95242 Facility Phone#:(209)365-7383 <br /> Legal Owner: TEIXEIRA,MANUEL&ROSA New Owner? ❑Yes E No <br /> Owner Address: 11401 N DAVIS RD, LODI CA 95242 Owner Phone#:(209)761-4708 <br /> Community Facilities Provided b Cam Community Kitchen? ❑ Yes 19 No <br /> Men: Number of Toilets Number of Showers Numbt of L--roues <br /> Women: Number of Toilets Number of Showers or—vatories <br /> Housing Accommodations to be Utilized this Year: Occup ane•/D� <br /> Buildings Employees OA-1" <br /> Dormitories .tom VI /0I/ 4 toI-Z/ "I Crop <br /> SF Dwellings from —/—/—to_/_/ Crop <br /> Apartments <br /> Owner Owned( 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 <br /> Note <br /> TOTALS 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 /> 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. <br /> Fee Schedule j1q.3 <br /> Permanent Camp Annual Permit Fe( $35.00+ Number of Employees _ @$12.00 each=$ 1 27 <br /> Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ Late Application Fee S70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL EEE DUE$ i l C� <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1, Division 13 of the California Health <br /> and Safety Corte and Cha r 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name t>e9 A' - r �( Title ❑ Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address ry �ZPhone <br /> Applicant Signature - r' Date of Application <br /> Amount Paid Date of Payment Payment Type Chec eceipt# Received By Account ID <br /> I 1.9b 11 (2-31111/ � G //� / 0002958 <br /> Facility ID Program Record ID lPIE Q Assigned to /C— PWS ID <br /> FA0003381 PR0515617 2,7655' 2424-VELOSO-CACAPIT WA0515599 <br /> Report#:7066.rpt �Ir7IIL _ f ,_ I,� <br /> W vv�_ Application Printed:10/25/2011 <br />