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Joaquin County-Environmental Health Deltas PAYMENT <br /> 1868*IrazeltonAvenue-Stockton CA 95205-Phone: 2V%- 3420 RECEIVED <br /> ti u J LUl/ <br /> APPLICATION SAN JOA <br /> ENVIRONMENTAL HEALTH QUIN COUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT <br /> ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent housing Camps only) ❑Annual Permit for Calendar Year <br /> ❑Amended Permit: "Change of Operator *Change of Owner <br /> *Change of Operator Address "Change of Owner Address Permit ID 111: 0010973 <br /> 'Additional Employees State ID#: 39-15750-EH <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 (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)752-4255 <br /> Legal Owner: TEIXEIRA,MANUEL New Owner" ❑Yes ❑ No <br /> Owner Address: 11401 N DAVIS RD, LODI CA 95242 Owner Phone#:(209)761-4709 <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 /> Housinn Accommodations to be Utilized this Year: Occunanev Dates: <br /> B111IdtBPd h.mnIUYCCs <br /> Dormitories from -J—/-A—t1-7-to f!L-7I/i Crop Q�RY <br /> SF Dwellings �_ from _/ t_to_I_/_ Crop <br /> Apartments <br /> Owner Owned MH/RV Q+— Total Number of Days to be used this Calrndar Yew: 3� <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces <br /> LIOtt <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 staina..if camdp will not be usethis year but is intended for use in the future,Check Nis Bos and return this application. <br /> yf 'f500 Fee Schedule 15,00 <br /> Permanent Camp Annual Permit Fes $X00+ Number of Employees @$x00 each=$ 13-5• <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership 520.00=S <br /> ❑ Permanent Amendment Fee 520.00+ Number of Additional Employees Q$12.00each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=S <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE S <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 Cade and Chapter 1,Subchapter ,Title 25,California Code ofRegaladons. <br /> Applicant Name MtAMINk -faCtll7A_ Title ❑Partnership <br /> (Phase PRINT or TYPE) /�/ 1 1 ❑Cot <br /> Address 6, AoI N- OC�4/tc D `OSI, C'r Phone 0.0 17b)g7C)�uon <br /> Applicant Signature tt/�XJI <br /> Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Receivedpy Account ID <br /> aD 3 f C I_„[o I /SOI/ 0002958 <br /> Facility ID Program Record ID C,�1 KPT �/ {�/ Assigned to PWS ID <br /> FA0003381 PRO515617 2765 6219- DUNCAN WA0515599 <br /> Report#-7066 <br /> Application Printed.4/3/2017 <br />