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Sa,..,dquin County-Environmental Health Departm <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209-460 <br /> o cd 3 c 1 REcMF� <br /> ENVIRONMENTAL APPLICATIOHEALTH SAN O 1 '120 <br /> 10 <br /> PERMIT TO OPERATE t.-/VV gQUI/V <br /> EMPLOYEE HOUSING OR LABOR CAMP 46kr, ROIVM COU <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Din690p 'qt <br /> EN <br /> ❑Amended Permit: *Change of Operator *Change of Owner Y T <br /> *Change of Operator Address *Change of Owner Address Permit ID#: 0010973 <br /> *Additional Employees <br /> State ID#: 39015750 <br /> EH ID#: 39000333 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: TEIXEIRA,MANUEL DAIRY#1 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 ❑ No <br /> Owner Address: 11401 N DAVIS RD, LODI CA 95242 Owner Phone 9:(209)761-4708 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildin�s Employees <br /> Dormitories from 0(/ G(/ ZA(( to 1'L 1311 Crop <br /> SF Dwellings from /_/ to_/_I Crop <br /> Apartments <br /> Owner Owned MH/RV �, G� 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 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 <br /> JR Permanent Camp Annual Permit Fet $35.00+ Number of Employees @$12.00 each=$ l bo <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 $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ <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 Code and Cha ter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant NameXr��� Title �.6�Z1 �-� ❑Partnership <br /> (Please PRINT or TYPE) v <br /> El Corporation <br /> Address Phone 7 <br /> Applicant Signature _� Date of Application - r2 <br /> Amount Paid Date of Payment Payment Type Check/ReeVpt# Received By Account ID <br /> 1 a p o 'y 1 C, Lk9. 5 0002958 <br /> 1 EFacility ID Program Record ID PIE 7 Assigned to PWS ID <br /> FA0003381 PR0515617 2765 5362-WIESEMAN WA0515599 <br /> Report#:7066.rot Application Printed:11/2/2010 <br />