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S oaquin County-Environmental Health Departs PAYMENT <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 RECEIVED <br /> r•1-- I — <br /> • T <br /> ' v LV IT <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH sAN.IOAgENYIRONMUIN cEitTP,r-, <br /> � <br /> PERMIT TO OPERATE HEALTH DEPApT• <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ElAnnual Permit for Calendar Year <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID N: 0010973 <br /> *Additional Employees <br /> 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&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 ❑ No <br /> Owner Address: 11401 N DAVIS RD, LODI CA 95242 Owner Phone#:(209)761-4708 <br /> Community Facilities Provided by Camo: Community Kitchen? ❑ Yes No <br /> Men: Number of Toilets Nt•yNg Number of Showers Number of Lavatories <br /> Women: Number of Toilets ,�4r:ag Number of Showers Number of Lavatories EN[ <br /> Housin¢Accommodations to be Utilized this Year: Occuoancy Dates: <br /> Buil in Employees FE 014 <br /> Dormitories from _/_/ to /_/ Crop <br /> from _/_/ to Crop Cro ERONM qL <br /> SF Dwellings � P Ncei <br /> C i <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3 ro�C— <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 more days in a year <br /> Require a PUBLIC WATER SYSTEM <br /> 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 <br /> (� Permanent Camp Annual Permit Fe( $35.00+ Number of Employees _ @$12.00 each=$ .— <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 AYMENT <br /> TOTAL FEE DUE ED <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope FEB + 9J 20+1� <br /> MAKE CHECKS PAYABLE to EHD B 1 <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this projgF'k(gamp)4h1A1TIie operated <br /> p lTAI, <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 oftttidfornta-Health and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. 4EA,. <br /> Applicant Namea Title �� � Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address p , Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment n 1Payment Type Check/Receipt# Received By Account ID <br /> 1`�•OD 02-1121- 1 IDYL C G� ��l z 7 1 � 0002958 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0003381 PRO515617 2765 2424-VELOSO-CACAPIT WA0515599 <br /> o....,...«.�ncc Annliratinn Printp.d-10/17/2013 <br />