Laserfiche WebLink
PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E Hazelton Avp-Stockton CA 95205-Phone: 209468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN JOAQUIt4 C <br /> PERMIT TO OPERATE EN�RON TUNn' <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEP ENT,4L <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit for C'alcnd;tr\ � <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 this form. <br /> Site Name: VANDER SCHAAF DAIRY#139-328 Location: 12739 S MURPHY RD ESCALON <br /> Operator: VANDER SCHAAF DAIRY 4139-328 Email: _5 t9 , CO l"1 <br /> Mailing Address: 13749 MURPHY RD,ESCALON CA 95320 Facility Phone#: (209)838-3947 <br /> Legal Owner: LAZY J RANCH LP New Owner? ❑ Yes [�(N. <br /> Owner Address: 13749 MURPHY RD,ESCALON CA 95320 Owner Phone#: (209)595-7687 Email: 0LPW V< O �i <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 /> Buildings Employees <br /> Dormitories from / / to / / Crop <br /> SF Dwellings from I / 1 /,211 to 0 131 /Ak 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 /> [� Permanent 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 <br /> TOTAL FEE DUE$ F f J <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,Title 25,California Code of Regulations. <br /> Applicant Name c1 10 CG VAD;'� S(' Title � � CE Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address p�, Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By <br /> Facility ID Progra Record ID P/E Assigned to PWS ID <br /> FA0003465 PR0515602 765 ena LeRoy <br /> Report#:7067.rpt <br />