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'I'AN JOAQUIN COUNTY • PUBLIC HEALTH SERVICES <br /> RNVIRONMENTAL HEALTH DIVISION <br /> 304 K WEBER AVENUE • THIRD FLOOR • STOCKTON CA 95202 • Phone: 209/468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit 6VA..uai Permit For Calendar Year <br /> ❑Amended Permit ❑Maitlple Years(Permanent Housing Camps only) )ate Approved <br /> • Change of Operator -(-hange ofo caner Pate Maned: '„ l cC <br /> • Change of Operator Address • Change of Owner Address ermil# <br /> • Additional Employees r. <br /> am ill# <br /> Please Note any Corrections or CN es In FacUIV00peraforliOwner Information directly on this form <br /> Site Name: MARTIN DAIRY 3q--;3-3 I,ocaUou:XXXX—�X t Nt.� )(MAUX 1 1 4 9 3 N. Davis Road <br /> -- --- --- <br /> Operator: MARY MARTIN <br /> Malting Address: 11363 N DAVIS RD,LODI CA 95242 Facility Phone#: 209-466-9202 <br /> Legal Owner: MARTIN,MARY -- - _ — — -- --- tew Owner ❑Yes ❑No <br /> Owner Address: 11363 N DAVIS RD,LODI CA 95242 Owner Phone#: 209-466-9202 or <br /> Community Facilities Provided by Camp: Community Kitchen: 0 Yes 0 No 368-6135 <br /> Men: Number of Tolled Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: <br /> Balldism Employees - l i 9--ploy <br /> Dormitories: Owner Owned MH/RV <br /> SF DwellingsOwner Owned RR Ca —— <br /> A artments --1_ —1— MH/ n <br /> - RV Spaces <br /> P TOTAL of Both COLUMNS <br /> Occupancy Dates: �� <br /> from_� to—� (kap Total Number of Days to he used this Calendar Year by <br /> from to CraTotal Days Occupied by 23 or more F,mplayees C7 <br /> ——— —— — p— Note: Camps rrcupred by 25 or more emsplopees for 60 or neuro days a}vurr <br /> require a 11WA to Water System Permit <br /> ❑ <br /> Inactive ( In order to protect your land use statux if camp will not be u wd this year bid is iwtendedfbr mss is tko fJetism CAeck thus Box and return <br /> this apiaNcattm <br /> Fee Schedule <br /> N <br /> Permanent Camp Almual Permit$3500+Number orEmpieyees � $12,00 each-S <br /> ❑ Orchard Camp Permit Fee=$95.00=S <br /> t ❑ Transfer of Ownership=$20.00-S <br /> ❑ Pernilt Amendment=$20.00+Number of Additional Employees @$12.00 each=$ <br /> ❑ Late Application Fee$70.00+Number of Employees (a)$24.00 each=$ <br /> Fee must be submitted with Application TOTAL FEE DUE: <br /> REMIT TOTAL FEE AS CALCULAIFD ABOVE.IN THE ENCLOSED self-addressed ENVELOPE. M4)W CHErXT PAYABLETt1: PTTS/FIID <br /> Applicant agrees to all necessary inspections Incident to Issuance of a PERMrrTO OPERATE. Applicant agrees that this project(camp)shall <br /> be operated and maintained In accordance with the applicable provisions of the EMMOYEIR HOUSING ACT,Chapter 1,Part 1,Division 13 or the <br /> Heafth and Safety Code and Chapter 1,Subchapter 3,Title 25,CdUJbrnia Code of Regulations. <br /> Applicant Name Maw Martin DBA Martin Dairy — Title Owner ❑Partnership ❑Corporation <br /> (PleamPRW°rlypi) Address 11363 N. Davis Road Lodi CA 95242 <br /> - — Phone-368-6135 <br /> Applicant Signature —-- -- - --- Date or Application <br /> 1-2-1-10/9 9 <br /> Program Record IDM 200105 Facility ID# 003381 Account ID# 00021158 <br /> Amara Pelt Date t Payment TVpe # Ived <br /> Employee• Acd it. ID: PR k PWS ID*. per: <br /> 'J <br />