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QPAYAIENT <br /> San Joaquin County-Environmental Health Department \ECE/VE® <br /> 1868 E Hazelton Ave-Stockton Ca 95205-Phone: 209468-3420 MAY <br /> APPLICATION <br /> ENA'IRON\IENTALHEALTH E OgQVWROIV�N <br /> EMPLOYEE HOUSING ORPERMIT TO LABOR CAMP H�,4 DEAR <br /> �y�C+LU <br /> ❑New Camp E]ConditionalPermit El MultipleYears(Permanent Housing Camps only) ® Annual Permit for Calendar Year 2026 ,�n'1l''eJ9-r <br /> ❑ Amended Permit: "Change of Operator "Change of Owner <br /> `Change of Operator Address "Change of Onncr Address <br /> "Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in FaciliryiOperator Information directly on this form. <br /> Site Name: \IACILADO DAIRY FARNIS#2 39-351 Location: 19405 E MARIPOSA RD STOCKTON <br /> Operator: NLAC1-1 ADO DAIRY FARNfS#2 39-331 Email: ✓?0 4. 9 k D�0 �q, i, • <br /> Nlailing Address: PO BOX 4430,NLANTECA CA 95337 Facility Phone#: (209)825-1913 <br /> Legal Owner. NLACHADO,DONALD A AN'D JOHN A New Owner" ❑ Yes D-90 <br /> Owner Address: PO BOX 4430,NLAN'TECA CA 95337 Owner Phone#: (209)8?5-1913 Email <br /> Communitv Facilities Provided by Camp. Community Kitchen? ❑ Yes ❑ No <br /> Nlen: Number of Toilets f: NumberofShotvers NuunberofLavatories 11j%fy <br /> Women: NumberofToilets �f J NumberoCShoNvers Ntanbe-rof Lavatories <br /> Housing Accommodations to be Utilized this Year, Occupancv Dates: <br /> Buildings Emplovees <br /> Dormitories d_ from / / to / / Cropdy+ <br /> y <br /> SF Dwellings from / / Lo / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> •� <br /> Owmer Owned RR Cars Total Days Occupied by 25 or more Employers. <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 SYSTEtht 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 S� <br /> [ Permanent Camp Annual Permit Fee S54.00+ Number of E-mployecs (u).S 17.00 each=b <br /> i <br /> ❑ Transfer ofOvvnership S25.00=S <br /> ❑ Permanent Amendment Fee $25.00+ Number ofAdditional Employees S 1700 each=S <br /> ❑ Late Application Fee S 108.00+ Number of Employees @ S34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE S � <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed Envelope <br /> i\LAKE 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 EiNIPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and <br /> Safety Cade and Chapter 1,Subchapter 3,Title 25,California Code ofReaa/ations. <br /> -" �n <br /> .applicant Namc ��1 <br /> ,�� _ ,/�I i�� � � �� Title A,&,4r1 e,- D arinership <br /> (Please PRINTor TYR,F� ❑Corporation <br /> Address 1" °. it " t?� Phonet��-�a - <br /> Applicant Signature Ce Date of Application <br /> Amount Paid Date of Payment Payment Type Ch Receipt# Received By <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0003372 PRO515621 2765 'asuna Tbanuuavongsa <br /> Report#:7067.rpt <br />