Laserfiche WebLink
aqum County-Environmental Health Depai��* PAYMENT <br /> 600 Main Street-Stockton CA 95202-Phone: 209-468-3420 RECEIVED <br /> APPLICATION SAN JOAOUIN CG,,,. <br /> ENVIRONMENTAL HEALTH ENMRONMEw, <br /> PERMIT TO OPERATE HEALTH DEPA-- <br /> EMPLOYEE HOUSING OR LABOR CAMP <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#• 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 ❑ 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 nJ0NF— Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories ENT <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees FEB ' O'(� <br /> Dormitories from /_/ to_/_/ Crop SAN <br /> SF Dwellings from _/_/ to_/_/ Crop NFeRONM AL <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: to <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 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 \1 <br /> [� Permanent Camp Annual Permit Fet $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 C$24.00 each=$ <br /> Fee must be submitted with Application AYMENT <br /> TOTAL FEE DUE1RED <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EHD FEB 1 3 2014 <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this projggp(gxmp)slflAff' be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 oltd(sJornia Health and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name �� iE a X!—i p;,4-- Title �� 'a ❑Partnership <br /> (Please PRINT or TYPE) <br /> ❑Corporation <br /> Address 1 p a - Phone ?j/� a 2j <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 1 19•av a/3 I �S 1 'L�_ -- 0002958 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0003381 PR0515617 2765 2424-VELOSO-CACAPIT WA0515599 <br /> Report#:7066 Application Printed:10/1712013 <br />