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San Joaquin County-Environmental Health Department <br /> 1868 E Ilazelton Ave-Stockton CA 95205-Phone: 209468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEAuni <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit for Calendar Year 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 A`oie any Corrections or Changes hi FacilitviOperator Information directly on this forur. <br /> Site Name: MACHADO DAIRY FARNIS#2 39-351 Location: 19405 E NIARIPOSA RD STOCKTON' <br /> Operator: NIACIIADO DAIRY F.ARNIS#2 39-351 Email: <br /> Mailing Address: PO BOX 4430,MANTEC.A CA 95337 Facility Phone#: (209)825-1913 <br /> Legal Owner: MACHADO,DONALD A AND JOHN A New Owner? ❑ Yes ❑ No <br /> Owner Address: PO BOX 4430,NIANTECA CA 95337 Owner Phone#: (209)825-1913 Email <br /> Community Facilities Provided by Camp: Community Kitchen'? ❑ Yes ❑ No <br /> Men: NumberofToilets 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 /> Buildings Employees <br /> Dormitories from / / to / / Crop <br /> SF Dwellings 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 <br /> 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 /> ❑ TransferofOwnership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Numberof Additional Employees u;$17.00 each=$ <br /> ❑ Late Application Fee $108.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE.DUE$ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed Envelope <br /> NIAKE CIIECKS PAYABLE to EIID <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 I,Division 13 of the California Health and <br /> Safeo,Code and Chapter 1,Subchapter 3,Title 25,California Code of ftula6ons. <br /> Applicant Name 'Title ❑Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0003372 PRO515621 2765 Sastina Thanunavongsa <br /> Report#:7067.rpt <br />