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PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E Hazelton Ave-Stockton CA 95205-Phone: 209468-3420 n F r 16 202- <br /> 02-APAPPLICATION <br /> PLICATION <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit for Calendar Ycar 2026 <br /> ❑ Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on thisform. <br /> Site Name: QUARESMA,RAYMOND AND SUE DAIRY Location: 26290 S UNION RD MANTECA <br /> Operator: QUARESMA,RAYMOND AND SUE DAIRY Email: <br /> Mailing Address: 5300 E PERRIN RD,MANTECA CA 95337 Facility Phone#: (209)918-7774 <br /> Legal Owner: QUARESMA,RAYMOND M&SUE New Owner? ❑ Yes No <br /> Owner Address: 5300 E PERRIN RD,MANTECA CA 95337 Owner Phone#: (209)679-3386 Email: uQ/rf-J!^i A, - t'i►�' 1 �� <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes No p+CL4 .,(!z- <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: Occupancy Dates: <br /> s s �f t <br /> Dormitories BuildingEmployeefrom / / / to 1`/3 I / �C' Crop )Ij <br /> SF Dwellings S from / / to / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> Important: In order to protect your land use status,if camp will not be used this year but is intended for use in the future,Check this Box and return this application. <br /> Fee Schedule <br /> PPermanent Camp Annual Permit Fee $54.00+ Number of Employees @$17.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $108.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application 1319 <br /> TOTAL FEE DUE$ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed 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 <br /> Safety Code and Chapter 1,Subchapter 3, le 25,California Code of Regulations. <br /> Applicant Name L,L r-rl c5 Title � h P� Partnership <br /> (Please PRINTorTYPE) ,/� ❑Corporation <br /> Address 53C-Z) i�L1�� ( /"i J � �Y 1t�fl- Phone W i(�� <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Chec Jc�eipt# Received By <br /> Pz . d b 1� � �7�� <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0003344 80515689 765 Rena LeRoy <br /> Report#:7067.rpt <br />