Laserfiche WebLink
SAN JOAQUIN COUNTY a PUBLIC HEALTH bWRVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 E WEBER AVENUE • THIRD FLOOR • STOCKTON CA 95202 • Phone: 209/468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> L New Camp El Conditional Permit ❑Annual Permit For Calendar Year <br /> J Amended Permit ❑Multiple Years(Permanent Hawing Camp:oaaly) )ate Approved <br /> • Change of Operator *Change of Owner ate Mailed: <br /> • Change of Operator Address • Change of Owner Address ermit# <br /> • Additional Employees am ID# <br /> Please Note any Correcitons or C ess In FaciUlylOpeAworlOwner I ormatton direr on this form. <br /> Site�me: 41) 04' S96VA-&TEIXEIRA DAIRY Location: 4+94 MOUNTAIN HOUSE PKW <br /> ----------- ---- --- -- <br /> ---------- ----------------- --------------------------------------------------------------- <br /> Operator: I <br /> TEIXEIRA DAIRY <br /> Mailing Address: 21997 MOUNTAIN HOUSE PKWY,TRACY CA 95376 Facility Phone#: 209-836-4081 <br /> Legal Owner: TEIXEIRA,ISIDORO A 74ew Owner ❑Yes d <br /> Owner Address: 21997 MOUNTAIN HOUSE PKWY,TRACY CA 95376 Owner Phone#: 209-836-4081 <br /> Community Facilities Provided by Camp: Community Kitchen: ❑Yes ❑No <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: <br /> BuIldlpM Employee vandbas Emnley <br /> Dormitories: Owner Owned MHMV 3 <br /> SF Dwellings —J — Owner Owned RR Cars <br /> Apartments MH/RV Spaces <br /> TOTAL of Both COLUl►M <br /> Occupancy Dates. <br /> from / / to / ! Crop Total Number of Days to be used this Calendar Year <br /> hvm—�/_to=/_�— Crop Total Days Occupied by 13 orxaore Employees <br /> —— -- Note: Camps occupied by 13 or more emplorees for 60 or more daps a year <br /> require a PxbNc Wafer.System PeMW <br /> 0 I native AWMMIW.• In order to protect your land use status,if camp will not be used this year but is hatexded far ase in aeJk&ur Gieek thus Box and return <br /> thus alppNcm Ym <br /> Fee Schedule / <br /> 1 Permanent Camp Annual Permit$35.00+Number of Employees b $12.00 each <br /> ❑ Orchard Camp Permit Fee=$95.00=S <br /> ❑ Transfer of Ownership=$20.00-S <br /> l ❑ Permit Amendment=$20.00+Number or Additional Employees @$12.00 each=$ <br /> D <br /> ❑ Late Application Fee$70.00+Number or Employees @$24.00 each=$ <br /> Fee must be submitted with Application TOTAL FEE DUE: <br /> RENUT TOTAL FEE As CALCULATED ABOVE IN THE ENCLOSED self-addressed ENVELOPE. MAKU CHECMPAYABLE TO: PHS/EHD <br /> Applicant agrees to all necessary inspections incident to Issuance of a PERMrr TO OPERATE. Applicant agrees that this project(camp)shall <br /> be operated and maintained in accordance with the applicable provisions of the FAM.oYss HOUSING ACT,Clwpter 1,Part 1,Division 13 of the <br /> Health and Safely Code and Chapter 1,Subchapter 3,Title <br /> /2-5,/Californiiaa Code of Regulations. <br /> — 64 <br /> Applicant Name J �axQ if( ��l l A <br /> Title (. WJ/ ��� ❑Paetayship ❑Corporation <br /> (Please PRINT or 7YP!] .#yC � <br /> Address �� /� ''(Qui�rl�/� l7vu��S�F�y K•�tt�7'. �� Phone aQ!— 36�'y`f 0�1 <br /> Applicant Signature:--l/ t� //yc.? ! t1�,L-/T C / Dsrte of Application - <br /> Program Record ID# 208041 Facility 1D# 003448 Account ID# 0003025 <br /> s <br /> AtYlt)ttTtt paid Date 9f Pa t mmt T t# Recehrcd Bv <br /> I C 7. 00 /z /� 9 <br /> Employee tit Acct it. I Fac ID: I PR e: PWS 1 . PTE: <br /> a-77s <br />