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N JOAQUIN COUNTY a PUBLIC HEALTH F VICES <br /> RNVIRONMENTAL HEALTH DIVIsi t4 <br /> 304 K WEBut AVENUE a THIRD FLOOR a STOCKTON CA 95202 • Phone: 209/468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> 1.1 New Camp ❑Conditional Permit ❑Annual Permit For Calendar Year <br /> LI Amended Perak U Multiple Years(Permanent Housing Camps ons )ate A roved <br /> • Change of Operntor •(Iianpe of Owner ate Malted: <br /> • Change of Operator Address -PChange of Owner Addren ermk# <br /> • Additional Employees 'am ID# <br /> Please Note any Correcdoas or Chwqex In F O enforpwner I ormadon directly on this form <br /> eName:r SQ4&k-&s TEIXEIRA DAIRY j Location_•-2+"MOUNTAIN HOUSE PKW <br /> - -- - -- --------------------------- <br /> Operator: �'S TEIXEIRA DAIRY <br /> Malting Address: 21997 MOUNTAIN HOUSE PKWY,TRACY CA 95376 Facility Phone#: 209-836-4081 <br /> Legal Owner: TEIXEIRA,ISIDURO A. - 1ew Owner ❑Yes LNN <br /> Owner Address: 21997 MOUNTAIN HOUSE PKWY,TRACY CA 95376 Owner Phone#: 209-836-1081 <br /> Community Facilities Provided by Camp: Community Kitchen: 0 Yes 0 No <br /> Men: Number of Tollets Number of ShowersNumber of Lavatories <br /> Women: Number of Toilets Number of Shower Number of Lavaterles <br /> Housing Accommodations to be Utilized this Year: <br /> Emalevees B�!nQ--;! ��aL�' <br /> Dormitories- Owner Owned Nt"V _,3 _ <br /> SF Dwellings _ -_ �— Owner Owned RR Can <br /> Apartments MH/RV Spaces <br /> TOTAL of Both COLUMNS <br /> Occupancy Dates: <br /> from to Crop Total Number or Days to he owed thle Calendar Year O <br /> —� —� — CSvp Total Days Occupled by 23 or near.-Employees J <br /> from——— ——-- Mole: Canps occuped by 23 or more exyWoyees for 60 ornwre days a year <br /> req a re a Pui/e Water System Perm& <br /> D I nactiVe jOWNGIMM In order to protect your land usv status•if camp will not be uwd this year bid Isinteadedfar use in AeJida m Cieck this Biu and return <br /> the s ajrrunm1au. <br /> Fee Schedule rDA <br /> I ❑ Permanent Camp Amual Permit$3500+Number of Employees $12.00 each <br /> �/ ❑ Orchard Camp Permit Fee=$95.00–S <br /> 3 - '/ <br /> 3� ,� 30 ❑ Transfer efOwnership=$20.00–S <br /> ❑ Permit Amendment=$20.00+Number or Additional Employees @$12.00 each=$ <br /> ❑ Lute Application Fee$70.00+Number of F.mpleyees @$24.00 each=$ <br /> Fee must be submitted with Application TOTAL FEE DUE: <br /> REMIT TO'T'AL FEE AS CALCULATED ABOVE IN IME RNCLo ED sett-addressed ENVELOPE. M4U OIRCIM PAYARLIF TO: PIISt/EIID <br /> Applicant agrees to ail necessary inspections Incident to Issuance of a PERmrrTo OPxRATB. Applicant agrees that this project(camp)shall <br /> be operated and maintained In accordance with the applicable provisions of the EMrt.OYES Hous>rro ACT,Chapter 1,Part 1,Division 13 of the <br /> He4M NMI Se fdy Code and Cbapfer I,Subchapter 3,Title 2%Cdifornta Code ofRegulndons. <br /> Applicant Name �t �r —1 Y %/f�Q /'1 <br /> C� /(� / [/'\ ( t Title (i1(��j/t//�e(� 0 Purbmddp 0 Corporation <br /> (PleasePt?ITfIo.7SPI) Address I !�j7 �DCt,tJ`�#lam 1- 04.11 S-F I7K�7IJV. Phone )m'— <br /> Applicant <br /> Appllcaot Signnlure��.���� �i �� � if/y ,� � Cl�l--/( !� f 6 Date of Application t � . I��i <br /> Program Record ID# 200041 Facility iD# 003448 Account ID# 0003025 <br /> Anvix t Paid Date Pay—wt Type-- t# Received By <br /> Employee tX Add i Fed ID: PR aw: PWS 1 PE: <br /> o b70(oa77S <br /> fp, 515590 <br />