Laserfiche WebLink
PAYMENT <br /> S oaquin County-Environmental Health Departs. RECEIVED <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209468-3420 <br /> DEC 30 ?013 <br /> APPLICATION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH ENVIROMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑ New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) aAnnual Permit for Calendar Year ZAO' <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0019362 <br /> *Additional Employees <br /> State ID#: 39-15751-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000425 <br /> Site Name: S C RANCH 39-425 Location: 17421 E COMSTOCK RD, LINDEN <br /> Operator: A SAMBADO&SON INC <br /> Mailing Address: 8077 N TULLY RD, LINDEN CA 95236 Facility Phone#:(209)931-2568 <br /> Legal Owner: SAMBADO,LAWRENCE J&BEVERLY New Owner? ❑Yes No <br /> Owner Address: 8077 N TULLY RD, LINDEN CA 95236 Owner Phone#:(209)931-2568 <br /> Community Facilities Provided by Camn: Community Kitchen? ❑ Yes [ No <br /> Men: Number of Toilets F Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Emoloyees <br /> Dormitories from 01 / Of/-L yyA to lol /�/� Crop t LN Lij-S <br /> SF Dwellings ,Z from _/ / to / / Crop <br /> Apartments <br /> Owner Owned 9/RV 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 <br /> Note <br /> TOTALS l () l {v Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> 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. <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fe( $35.00+ Number of Employees 10 @$12.00 each=$ a0. <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees a $24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$- 1 -r�'S, QQ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed 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 /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name LAWRENCE SAM13ADO Title PREELDENT ❑ Partnership <br /> (Please PRINT or TYPE) Corporation <br /> Address 90f717 &I. TULLY D._ L=NDEIV I CA gSa.3(« Phone(apg)931_asirelg <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment n r Payment Type Check/Receipt# Received By Account ID <br /> IScJ 'Ot7 1Z`3O r CGsC� `T�Z-'TJ 0033238 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0018722 PR0527631 2765 2424-VELOSO-CACAPIT WA0515744 <br /> Report#:7066 Application Printed:10/17/2013 <br />