BILLING - Laserfiche WebLink

Home Browse Search

S Joaquin County-Environmental Health Departm-_t 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 PAYMENT RECEIVED APPLICATION NOV �• 2011 ENVIRONMENTAL HEALTH .,,N JOAQUIN COUNTY PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR CAMP ^'TH DEPARTMENT ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year QD 1 S ❑ Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#• 0005643 *Additional Employees State ID#: 39-0321-EH Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000321 Site Name: A SAMBADO&SON 39-321 Location: 14000 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 No Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone#:(209)931-2568 Community Facilities Provided b,CaruLk: Community Kitchcn? ❑ Yes ❑ No Men: Number of Toilets I Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories 1{ousine Accommodations to be Utilized this Year: Occupancy Dates: Buildines Employees Dormitories from/Of/ 115 to JC_L/,3t/_18_ Crop ) SF Dwellings p� r from _/_/ to_/_/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3lo 5 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: NON E ME/RV Spaces Note TOTALS C Camps occupied by 25 or more Employees for 60 or more days in a year 5 © Require a PUBLIC WATER SYSTEM Permit ❑Inactive Im op rtant: 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 Fec $50.00+ Number of Employees 15 @$15.00 each=$ ❑ 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 C)^^^ TOTAL FEE DUE$ t�75.t-�l_/ 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 alifornia Code of Regulations. /� Applicant Name LAwR em $ADD Title t�FNT (J 1 F2 partnership (Please PRINT or TYPE) '—�—^ orporation Address gorY7 N, l uLLY D. LZN DEM R • Q CS QR( Phone Applicant Signature Date of Application 110—3 Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 0003775 CfL � � ? ( Facility ID Program Record ID PIE Assigned to PWS ID FA0004113 PR0270321 2765 8987-SANGALANG WA0515747 Report#:7066 Application Printed:10/23/2017