Laserfiche WebLink
1 ' �� � <br /> San Joaquin County- Environmental H r �_020 <br /> Health Department �fl✓` <br /> 1868 F.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 <br /> • G�-� L.1 4h � L 1 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> Nv,Cam <br /> p ❑Conditional Permit ❑ Multiple Years(Perz„ancnt[lousing Camps only) �Annual Permit for Calendar Year t7C�1C\ <br /> ❑ Amended Permit: *Changeof Operator *Change of Owner <br /> *Changeof Operator Address *Change of Owner Address Permit ID!�: 0011034 <br /> *Additional Employees <br /> State ID#: <br /> Please Nole any Corrections or Changes in Facilitv/Operator Informction directly on thisform. EH ID th 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 T ❑Yes G3 No <br /> Owner Address: 5300 E PERRIN RD,MANTECA CA 95337 01-net Phonc 9:(209)825-7774Ext: FAX <br /> Community Facilities Provided by Cimpi Community Kitchen? ❑ Yes �" No <br /> Men. Number of Toilets dumber of Showers Number of Lavatories <br /> Women.- Number of Toilets Number of Showers N umber of Lavatories <br /> Housing Acenrnonodations to he Iltili7ed this Year: Occupancy Date: <br /> Building Employees <br /> Dormitories from / /v Qs7to . 13 i/ e i` Crop <br /> SF Dwellings from / / to Crop <br /> _/ / <br /> Apartments <br /> Owner Owned ME/RV Total Number ofDays to be used this Calendar Year: <br /> REC niEep <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> NIH/RV Spaces AN <br /> TOTA LS ( j Cam ps occupied by 25 or more Employees for 60 or more days in a year <br /> �4 <br /> Require a PUBLIC NVATER SYSTEM Permit SANJOAQUfNepU <br /> • ENVIRONAI HTY <br /> Inactive NFAtTNQFPA MS <br /> ❑ T <br /> l ui aorta nC In order to protect your land use status,if camp will not be used this year but is intended:or use in the future,Check this Box and return this application. <br /> Fee Schedule <br /> (� Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$17.00 each=$ / 4 <br /> ❑ Transfer of Ownership <br /> $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @ S 17.00 each=$ <br /> ❑ [,ate Application Fee $1'00.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ <br /> Remit TOTAL FEE as CALCU1_4TED 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 and Safery Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant name �l` .:� i/.-� l/u r , Title [`Jy',Zj "li <br /> (Please PRINT or TYPE) r "�`'p l '--"`� Y�-t-.,t— Partnership <br /> Address r�— �/7 ' h_ �LL+ Corporation <br /> �C7J T Il. iL1,-,- --'[ ( vyn r�r., 1y d�, 'l .M,� t �� Phone 1 <br /> applicant Signature 1 - ? �! Date of Application <br /> A ountrrPPaid Oat of Payment Payment Type CheckiRecetpt# Received By Account ID <br /> 0002921 <br /> Facility ID Program lRecord ID PIE Assigned to PALS ID <br /> FA0003344 PRC515689 2765 0039-GOODERHAM WA0515676 <br /> teoort tf:7066 <br /> fApplication Prin'ed:11/112023 <br /> MEN <br /> 01 l � MEN <br /> ■ ■ <br /> L'd �LLL-5Z8-60Z l.2jlba bWS�?�bflb BLOW <br /> t1Z 8Z <br />