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USAN JOAQUIN COUNTY • PUBLIC HEALTH VIMIVICES k) t/ o ENVIRONMENTAL HEALTH DIVISION 304 E WEBER AVENUE • THIRD FLOOR • STOCKTON CA 95202 • Phone: 209/469-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit Annual Permit For Calendar Year �J Amended Permit ❑Multiple Yeas(Permanent Housing Camps orely) Oate Approved • Change of Operator -Change of Owner Me Mulled: • Change of operator Address • C'hange of Owner Address etmhf'15� • Additional Employees am Please Note an Corrections of Changes In F :O eralorlOwner In ormadon direr on this form - Site Name: MARTIN DAIRY Location: 1`MMY16A XX 1 14 9 3 N. Davis Road --------------- ------------ — --------------- - — - - - — — Operator: MARY MARTIN Malling Address: 11363 N DAVIS RD,LODI CA 95242 Facility Phone#: 209466-9202 Legal Owner: MARTIN,MARY �ew Owner ❑Yes ❑Nq Owner Address: 11363 N DAVIS RD,LODI CA 95242 Owner Phone#: 209-466-9202 or Community Facilities Provided by Camp: Community Kitchen: 0 Yes 0 No 368-6135 Men: Number of Toilets Number of Showers Number of Lavatorles_ Women: Number of Toilets Number of Showers Number of Lavatories HouslnQ Accommodations to be Uf tzed this Year: Buildl Employees Buildings Employee: Dormitories: Owner Owned MH/RV r � SF Dwellings _ Owner Owned RR Cars Apartments MH/RV Spaces _ TOTAL of Both COLuNm, Occupancy Dates: ��/C('� -) from to—�—J rop Total Number of Days to be used this Calendar Year from= to—�—� Crop Total Days Occupied by 23 or more Employees Note: Camps occupied by 23 or more employees for 60 or more dogs n,gew regui re a Pkw Wnler System Perm& ❑ Inactive In order to protect your land use status,i•f camp wzR not be used this year but is iWeudedfor use to tie f shim Geek this Brix and return this app cadas. Fee Schedule Lq/permanent Camp Annual Permit$35.00+Number of Employees _Lam—$12.00 each-$ $ (L) E" Orchard Camp Permit Fee=$95.00=S ❑ Transfer of Ownership=$20.00=S ❑ Permit Amendment=$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-addressed ENVELOPE. t1 4jw CHECKS PAYABLE TO: PHS/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 FMPLOYEE HOUSING ACT, Chapter 1,Part 1,Division 13 of the Health and Safety Code and Chapter 1,Subchapter 3,Title 25,Caltfortlla Code ofRegu/adoru. Applicant Name Mary Martin DBA Martin Dairy Title Owner []Partnership ❑Corporation (PleacePrLwornFE) Address 11363 N. Davis Road Lodi CA 95242 Lodi, -_ Phone 368-6135 Applicant Signature Date of Application 12/1 0 9 9 Program Record ID# 200105 Facility ID# 003381 Account ID# 0002958 Amomt Paid Date Of Pa t Payment T t# tvedkv Employee#t Act:/lr F ID: PR e. PWS IDK: I per. 77