BILLING - Laserfiche WebLink

Home Browse Search

Joaquin County-Environmental Health Department REC MVNT 1868 E.Hazelton Avenue Stockton CA 95205 Phone: 209 468-3420 No D 4 < 2n12 APPLICATION hDNM ErNn EPgENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) XAnnoal Permit for Calendar Year ao t []Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#: 0011914 *Additional Employees State ID#: 39-15729-EH Please Note any Corrections or Changes in Facility/Operator Information directly on thisform. EH ID#: 39000370 Site Name: A SAMBADO&SON 39-370/WTR SYS Location: 15294 E EIGHT MILE RD, LINDEN Operator: A SAMBADO&SON INC Mailing Address: 8077 N TULLY RD, LINDEN CA 95236 Facility Phone#:(209)931-2568 Legal Owner: SAMBADO, LAWRENCE J&BEVERLY New Owner? ❑Yes h No Owner Address: 8077 N TULLY RD, LINDEN CA 95236 Owner Phone#:I(209)931-2568 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets Number of Showers Number f Lavatories Women: Number of Toilets Number of Showers Number Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildine Emolovees �1, Dormitories from /Q/1�to ov 31 /_t_5 Crop O SF Dwellings —�— from_/_/ to / / Crop Apartments Owner Owned ME/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: ME/RV Spaces T —1tZ Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive m hortant: 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. Fee Schedule �^ Permanent Camp Annual Permit Fee $50.00+ Number of Employees �_ @$15.00 each=$ t 3 W o. Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application TOTAL FEE DUES o1 O0. Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1, Part 1, Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name LAL)RF_it�1CF �A/1� �_ Title O R [I Partnership (Please PRINT or TYPE) )(Corporation Address W77 N. `Tr'LLLY RD. _ LTAQW . LA a5034o Phone Clog-g31-a5b3 Applicant Signature Date of Applicationt 0—`3(—17 Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 0023136 v �r � a -7 c (L ? � 7 Facility ID Program Record ID PIE Assigned to PWS ID FA0013764 PR0518217 2765 6219-DUNCAN WA0515716 Report#:7066 Application Printed: 10/23/2017