Laserfiche WebLink
1 ' �� � <br /> San Joaquin County- Environmental Hr �_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 <br /> New Owner T ❑Yes G3 No <br /> Owner Address: 5300 E PERRIN RD,MANTECA CA 95337 O1-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 /> SP 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 /> 13T <br /> l ui porta 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 Bos 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 1.O OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of lite EMPLOYEE HOUSING ACT,Chapter 1, Part 1,Division 13 of the California Health <br /> 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-.,— 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 - ? �! Date of Application <br /> A ountrPPaid Oatof Payment Payment Type CheckiRecetpt# Received By Account ID <br /> lJ l D8 0002921 <br /> Facility ID Program lRecord ID PIE Assigned to PAIS ID <br /> FA0003344 PRC515689 2765 0039-GOODERHAM WA0515676 <br /> teoort tf:7066 <br /> fApplication Prin'ed:11/112023 <br /> MEN <br /> 01 l � Mi <br /> ■ ■ <br /> L'd �LLL-5Z8-60Z l.2jlba bWS�?�bflb BLOW <br /> t1Z 8Z <br />