Laserfiche WebLink
r� } <br /> PAYMENT <br /> San Joaquin Coun RECEIVED <br /> q t}'-Em'ironmental Health Department <br /> 1868 E Hazelton Ave-Stockton CA 95205-Phone: 209468-3420 F B Q 0 <br /> APPLICATION <br /> ENITROX,A NTAL HEALTH SAN JOAQUIN COUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT <br /> ❑New Camp ❑Conditional Permit ❑ Ntuldple Ynrs(Permanent Housing Camps only) 2026 <br /> p )) ® Annual Permit for Calendar Year <br /> ❑ Amended Permit "Change of0perator 'Change of Owner <br /> 'Change of Open for Address 'Change of Owner Address <br /> *Additional Employees <br /> State[D 4:39-0040-EH <br /> Please Note any Corrections or Changes in Faciliti/Operator Information direclly on this form. <br /> Site Name: LARSEN RANCH 3940/WATER SYSTEM Location: 5125 S KAISER RD STOCKTON <br /> Operator. LARSEN RANCH 3940ANIATER SYSTEM Email: <br /> Mailing Address: PO BOX 4403,NLANTECA CA 95337 Facility Phone#: (209)851-5650 <br /> Legal Owner LARSEN,BARBARA New Owner? ❑ Yes ❑ No <br /> Owner Address: PO BOX 4403,NLANTECA CA 95337 Owner Phone#: (209)851_5650 Entail. <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes 'Q No <br /> Men: Number of Toilets NumberotShowers Number of Lavatories <br /> Women: NumberofToilets Number ofSho+vers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year Occupancy Data: <br /> Buildings Emplovees <br /> Dormitories from / to Crop <br /> SF Dwellings from / / to / Crop <br /> Apartments ' <br /> Owner Owned MH/RV —41 <br /> 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 Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> L=�J Inactive Require a PUBLIC WATER SYSTEM Permit <br /> ❑ �" <br /> Important: In order to pro(eet 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 S54.00+ Number of Employees (aS 17.00 each=S #v y <br /> ❑ Transfer of Ownership $25.00=S <br /> ❑ Permanent Amendment Fee S25.00+ Number of Additional Employees @ S 17.00 each=S <br /> ❑ Late Application Fee $108.00+ Number of Employees @$34.00 each=S <br /> Fee must be submitted with Application <br /> TOTAL FEE DUES <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 /> Safeq-Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name Title \j.i 11ej- ' ❑Partnership <br /> (Please PRINT or TYPE) ! ❑Corp o ration <br /> :Address � Phone � � I �— ?7— ' — <br /> ; <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 PyyS ID <br /> FA0002805 PRO270040 765 Sastina Thammavongsa <br /> Report#:7067.rpt <br />