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San Joaquin County-Environmental Health Department PAYIy�EN7RE <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 CE/V ED <br /> OR- n on <br /> �4F.Vi - <br /> APPLICATION SAN JOAQUI CO <br /> ENVIRONP RMITITO O ERATEENTAL TH HEATH DEPAF TT NTr <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑ <br /> /J 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 4: 0011034 <br /> *Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000353 <br /> Site Name: QUARESMA,RAYMOND&SUE DAIRY INC 39-353 Location: 26290 S UNION RD,MANTECA <br /> Operator: QUARESMA,RAYMOND M <br /> Mailing Address: 5300 E PERRIN RD,MANTECA CA 95337 Facility Phone#:(209)825-7774 <br /> Legal Owner: QUARESMA, RAYMOND M&SUE New Owner? ❑Yes ❑ No <br /> Owner Address: 5300 E PERRIN RD,MANTECA CA 95337 Owner Phone#:(209)825-7774Ext:FAX <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 /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> uildin! Employees <br /> Dormitories from I/ /Cz A to I QL/ 31//_';3 Crop a I+tet <br /> SF Dwellings C from _/_/ to_/_/ Crop <br /> Apartments —v�— <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: PAT <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: RECF1VE71 <br /> MH/RV Spaces N <br /> ote TOTALS 4 Camps occupied by 25 or more Employees for 60 or more days IWO 2 2023 <br /> Require a PUBLIC WATER SYSTEM Permit <br /> SAN JOAQUIN COUNTY <br /> Inactive ENYIRONMENTAL <br /> Im oD rtant: In order to protect your land use status,ifcamp will not be used this year but is intended for use in the future,Check this Box and return this applicationEALTH oErARTMENr <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$17.00 each=$ <br /> ❑ IS— <br /> Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application f 2 <br /> TOTAL FEE DUE$ l <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 Cha 1,Subchapter 3,Title 25 lifornia o of Regulations. <br /> A 1 <br /> licant Name q,yl� �/ Partnership <br /> PP �n_,,� �" l.�f�1- 1,(1�-f7�''.5�1_ Title �j � p <br /> (P/ease PRINT or TYPE) - 1 ' j 3-� Corporation <br /> Address ` 3�� !S I I tY� n i Phone <br /> Applicant Signature Date of Application <br /> Amount Paid ate of aymekv I(,nt Payment Type Check/Receipt# Received Account ID <br /> 13 S /_ 3 Z 0002921 <br /> '__- <br /> Facility ID (�Program Record ID PIE Assigned to PWS ID <br /> FA0003344 PR0515089 2765 0039-GOODERHAM WA0515676 <br /> Report#:7066 <br /> Application Printed:11/28/2022 <br />