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f oaquin County-Environmental Health Depart. <br /> 1868 E.Belton Avenue-Stockton CA 95205-Phone: 2068-3420 PAYMENT <br /> RECEIVED <br /> APPLICATION I MV 0 <br /> ENVIRONMENTAL HEALTH am '0XQU*J COUKIN <br /> PERMIT TO OPERATE EW"MEWAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEjkt.TM oEPARTME>rT <br /> ❑New Camp []Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year�^12 <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 Information directly on this form. EH ID#: 39000333 <br /> Site Name: TEIXEIRA, MANUEL DAIRY#1 (39-333) 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 Ck No <br /> Owner Address: 11401 N DAVIS RD,LODI CA 95242 Owner Phone#:(209)761-4708 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes No <br /> Men: Number of Toilets /J A Number of Showers Number of Lavatories <br /> Women: Number of Toilets N JA Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildins:s Employees T <br /> Dormitories from _/ / to / / Crop SJ4,/L <br /> SF Dwellings t from _/ / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 36V <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> le— <br /> MH/RV Spaces N e <br /> �1_ <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 Tpp <br /> Permanent Camp Annual Permit Fe( $35.00+ Number of Employees @$12.00 each=$ D <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 Chapter 1,Subchapter itle 25,California Code of Regulations. <br /> Applicant Name V��-"V_L4 r15�� \l��,[[=C2� Title �..�tit��l ❑ Paztnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address Phone <br /> Applicant Signature " Date of Application <br /> Amount Paid Date of Payment Payment Type hec Receipt# Received By Account ID <br /> ��l �� 1� 7 � ✓ ,� 0002958 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0003381 PR0515617 2765 2424-VELOSO WA0515599 <br /> Report#.7066 Application Printed'10/15/2014 <br />