BILLING - Laserfiche WebLink

Home Browse Search

• in Joaquin County-Environmental Health Del nent 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 RECLI nll APPLICATION ENVIRONMENTAL S JA 2 2 ZO PERMIT TO OPERATE N�qQN//v O/ EMPLOYEE HOUSING OR LABOR CAMP yEgl RON CO(y Ty MENT Nry ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar 1re8t ❑Amended Permit: *Change of Operator *Change of Owner NT *Change of Operator Address 'Change of Owner Address *Additional Employees Permit ID 9' 1011114 Please Note any Corrections or Changes in Facility/Operator Information directly on tht. Camp ID#: 39000370 Site Name: A SAMBADO&SON 39-370 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 New Owner? ❑Yes ❑ No Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone#:(209)931-2568 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancv Dates: Buildings Employees Dormitories from llylll?lh to �_ 1�� Crop SF Dwellings from _/_/ to_/_/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: IZ1—M Owner Owned RR Cars Total Days Occupied by 25 or more Employees: /;10/JP MH/RV Spaces Note TOTALS Camps occupied by or more Employeesfor 60 or more days in a year Requiree a PUBLIC WATERER SYSTEM Permit ❑Inactive Im portan 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. Fee Schedule A Permanent Camp Annual Permit Fee $35.00+ Number of Employees 10 @$12.00 each=$ �070 T ❑ Orchard Camp Permit Fee $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 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 2.5,California Code of Regulations. Applicant Name � �r�Olf�p �nt/y�h�! �0 Title j7��vf�D��T ❑Partnership (Please PRINT or TYPE) Corporation Address 9d 7 A/ `,/,4 ?5-23 Phone A31 e• Applicant Signature Date of Application Amount Paid [ Date of Payment Payment Type C h e c Vei-pl# Received By Account ID 0023136 Facility ID Program Record ID PIE Assigned to V PWS ID FA0013764 PR0518217 2755 6916-BORGMAN N/A Report#:7066.rpt N V I Application Printed: 10/23/2006