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Joaquin County-Environmental Health Depar.,,.,j)t 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 12A MEE W APPLICATION ENVIRONMENTAL TO OPERATE I11 ►SAN dOMARONMEINT EMPLOYEE HOUSING OR LABOR CAMP 140101-ADEPAIa ❑New Camp []Conditional Permit ❑ Multiple Years(Permanent(lousing Camps only) ❑Annual Permit for Calendar Year '2 t7 -7 ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID N: 0010973 *Additional Employees State ID#: 39015750 Please Note any Corrections or Changes in Facility/Operator Information directly on this fonn. EH ID#: 39000333 Site Name: TEIXEIRA,MANUEL DAIRY#1 (39-333) Location: 11493 N DAVIS RD,LODI Operator: TEIXEIRA,MANUEL&ROSA Mailing Address: 11401 N DAVIS RD, LODI CA 95242 Facility Phone#:(209)365-7383 Legal Owner: TEIXEIRA,MANUEL&ROSA stew—Owner? ❑Yes 0 No Owner Address: 11401 N DAVIS RD, LODI CA 95242 Owner Phone#:(209)761-4708 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets Number of Showers Number of ories Women: Number of Toilets Number of Showers er of Lavatories Housing Accommodations to be Utilized this Year: Occu anc Da Buildings Employees 19�(� Dormitories from Of /o(/ 1Z to I Z/ / 2 Crop SF Dwellings 1 from _/ / to / / Crop Apartments Owner Owned(9RV 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 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 Bos and return this application. Fee Schedule ❑ Permanent Camp Annual Permit Fe( $35.00+ Number of Employees @$12.00 each=$ ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 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 Namet�5 �� Title OL Partnership (Please PRINT or TYPE) o ❑Corporation Address '� Phone ZVQ Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Chec eceipt# Received By Account ID � ' �� ✓ /�Q � � 0002958 Facility ID Program Record ID PIE Assigned to PWS ID FA0003381 PR0515617 2765 2424-VELOSO-CACAPIT WA0515599 Renort#:7066.rot Application Printed:10/25/2011