BILLING - Laserfiche WebLink

Home Browse Search

S oatluin County-Public llcalth Servic Environmental Ilealth Division PAYNAE'N•1 304 E Weber Avenue-Third Floor-Stockton CA 9521)2 - Phone: 209-468-3420 RF(;rIVF[` APPLICATION JAN ? 1(�0� ENVIRONMENTAL HEALTH PERMIT TO OPERATE = I EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Penuit for Calendar Year ❑Amended Permit: 'Change or Operalor *Change or Owner *Change or Operator Address 'Change or Owner Address 'Additional Employees Permit ID#: II005643 Please ,Vote rnry Corrections or Change- irl rocilihl/Operator h formation directly I Camp ID#: 39000321 Site Name: A SAMBADO&SON°3-321 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 New Chimer? ❑Yes ❑No O«ner Address: 8077 N TULLY RD,L114DEN CA 95236 Owner Phone#: (209)931-2568 Community Facilities Provided by Camp: Community Kitchen LJYcs EJ No Men: Number of Toilets Number of Showers Number of lavatories Women: Number of Tnilets Number of Showers Number of Lavatories Housine Accommodations to he Utilized this Year: Oc ►nc Dal Buildings Employees rron to_ Crop y-� �2 I-q, Dormitories t'rom_I_/_to__/ / Crop_ SF Dwellings e Apartments Total Nam her of Days to be used this Calendar Year �•�A Owner Owned MH/RV TotalDnyx0ecupiedby25orm(we EmploycesL-1 Owner Owned RR Cars Note: MH/RV Spaces Camps occupied by 25 or more employees for 60or more days in a year TOTAIS reYluire a Puhlic Water System Permit. ❑ lurnctive Important: 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. Tee Schedule ❑Permanent ('amp Annual Permit Fee: $35.00 Number ofEmployees (al, $1200 each=$ ! `�J♦ rfiA_.'� ❑ Orchard Camp Permit Fee: $95.00=$ ❑ Transfer of Ownership: $20.00=$ ❑ Permit Amendment Fee: $20.00 1 Number of Additional l;mployecs (a $12.00 each=$ ❑ Late Application Fee: $70.00 - Numbet oflirnployces _ (q) $24.00 each-$ Fee nwst be submitted witch Application TOTAL FEE DUE: $ RemitTOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope MAKE CHECKS PAYABLETO: PHS-EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall operated and maintained in accordance with the applicable proiisions of the EMPLOYEE HOUSING ACT, Chapter 1, Part 1, Division 13 of th California Ifeahh and Safely Corte and Chapter 1,Subchapter 3,Title 25,California Code ofRegulatious Applicant Name VaLo I"C.11 `,"� . `�.a�>r">jt�') 'L' Title ❑�Partnership (Please PRINT or TYPE) Ly COipOMc hOn Address r r (. a .� . ' ' f `- i `PhOnF)C Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID � J S S. (�D 1��D I ✓ J4 0003775 F rcility ID Program RFn:nrd ID PIE Assigned to PWS ID 0004113 0270321 2755 5366-MEDINA 0005643 Report 9:7066.rpt Applicalion Prinlod 11171'00