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RPAYMENr <br /> ECE <br /> San Joaquin County-Environmental Health Department Ive p <br /> 1868Eltazelton Ave-Stockton CA 9520i-Phone: 209468-3420 MAI ' ?non <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH E IV�qQU/W <br /> PERMIT TO OPERATE NE,q�NT R�lV NT UN7y <br /> EMPLOYEE HOUSING OR LABOR CAMP H D@ qR mac. <br /> ❑New Camp []Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit for Calendar Year 2026 TMENT <br /> ❑ Amended Permit: "Change of Operator "Change of Owner <br /> "Change of Operator Address "Change of Owner Address <br /> "Additional Employees <br /> State IU#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: MACHADO DAIRY FARMS#2 39-351 Location: 19405 E MARIPOSA RD STOCKTON <br /> Operator: MACI ADO DAIRY FARMS#2 39-351 Email: PM P4 11010 m t\ •G o wY <br /> Mailing Address: PO BOX 4430,MANTECA CA 95337 Facility Phone#: (209)825-1913 <br /> Legal Owner: MACI[ADO,DONALD A AND JOHN A New Owner? ❑ Yes oa*90 <br /> Owner Address: PO BOX 4430,MANTECA CA 95337 ()%oner Phone»: (209)825-1913 Email: <br /> Community Facilities Provided by Camo: Community Kitchen.1 ❑ Yes ❑ No <br /> Nlen: NumberofToilets MIANumberofShowers NIA _ NumberofLavatories JVIA <br /> Women: Number of Toilets NZA Number ofShowers NIA Number of lavatories /V <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildinos Employees <br /> Dormitories _7` from / / to / / Crop /r <br /> SF Dwellings _ from / / to / / Crop rt <br /> Apartments _ <br /> Owner Owned MH/RV 3 Total Number of Days to be used this Calendar Year: fo s <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> 7 <br /> MH/RV Spaces — Note <br /> TOTALS Camps occupied by 25 or more Employees for60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> El lnactiyc <br /> I nt port a n t: 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 /> I-ec Schedule oe <br /> Permanent Camp Annual Permit Fee $54.00+ Number of Employees j— Q$17.00 each=$ <br /> 777❑��� Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number ofAdditional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $108.00+ Number of Employees Qa$34.00 each=$ <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 /> 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 o Re I forts. <br /> Applicant Name _ Mae-A 4 V Title �i4 -�n etr [T!}Partnership <br /> (Please PRINT or ❑Corporation <br /> Address t t ea Phone .2o9-667--3YI-q <br /> le <br /> Applicant Signature 4.��> Date ot'Application <br /> Amount Paid Date of Payment Payment Type Ch Receipt# Received By <br /> 190.b0 S �r a � 79310 <br /> Facility ID Program Record ID HE Assigned to Pa'S Ili <br /> FA0003372 PR0515621 2765 Saitina Thamntaeongsa <br /> Report#:7067.rpt <br />