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�.r WOW <br /> San Joaquin County-Environmental Health Department PAYMENTRECEIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> MAR 17 2016 <br /> APPLICATION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL IIEALTH ENVIRONMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp []Conditional Permit ❑ Multiple fears(Permanent Housing Camps only) Annual Permit for Calendar Year 2'o tl� <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#; 0010973 <br /> Additional Employees <br /> State ID#: 39-15750-EH <br /> Please Note any Corrections or Changes in Facility/Operator Jnjormatinn directly on this form. <br /> EH ID#: 39000333 <br /> Site Name: TEIXEIRA,MANUEL DAIRY#1 (39-333) Location: 11493 N DAVIS RD,LODI <br /> Operator: TEIXEIRA,MANUEL <br /> Mailing Address: 11401 N DAVIS RD,LODI CA 95242 Facility Phone#:(209)365-7383 <br /> Legal Owner: TEIXEIRA,MANUEL® New Owner? ❑Yes ® No <br /> Owner Address: 11401 N DAVIS RD,LODI CA 95242 Owner Phone#:(209)761-411004 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ® No <br /> Men: Number of 7'oilets Al J rA Number of Showers Number of lavatories <br /> Women: Number of Toilets -7,k Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buddines Employees <br /> Dormitories from /oto (24 all Crop <br /> SF Dwellings �_ �_ from—/—/—to—/ / Crop <br /> Apartments <br /> Owner Owned MH/RV — — Total Number of Days to be used this Calendar Year 3 6 s <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: A6�_ <br /> M11/RV Spaces <br /> N4LC <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 /> Imnorlant: 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. <br /> Fee Schedule <br /> ® Permanent Camp Annual Permit Fet $35.00+ Number of Employees a$12.00 each=$ 101. <br /> 0 0 <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 C$24.00 each=$ <br /> Fee must be submitted with Application ;0 <br /> TOTAL FEE DUE S <br /> Remit TOTAL.FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> !HAKE 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,fart 1,Division 13 of the California Health <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,CnNfornia Code ofRegahrdons. <br /> Applicant Name _1F,1ro. Title ���j El Partnership <br /> (Please PRINT or TYPE) (� ❑Corporation <br /> Address �1 k01 N) ih�Ii_s RQ I " CA { 562 Phone d_rA '76'] L, <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0002958 <br /> Facility ID Program Record ID PIE / Assigned to PWS ID <br /> FA0003381 PR0515617 2765 6219-DUNCAN WA0515599 <br /> Report#:7066 Application Printed:3/3/2016 <br />