BILLING - Laserfiche WebLink

Home Browse Search

Joaquin County-Environmental Health Depa LA `YMEN RECEIVED 1868 h..iazelton Avenue-Stockton CA 95205-Phone: 209468-3420 ar'^ A n 9nt0 APPLICATION ENVIRONMENTAL HEALTH SAN JOAOUIN CUUNi> PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR CAMP / HEALTH DEPARTMENT pd ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year [-]Amended Permit: *Change of Operator *Change of Owner 7 C *Change of Operator Address *Change of Owner Address Permit ID#• 0019362 *Additional Employees State ID#: 39-15751-EH Please Note any Corrections or Changes in Facility/Operator Information directly on this form EH ID#: 39000425 Site Name: S C RANCH 39-425 Location: 17421 E COMSTOCK 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 �OwnerAddress: 8077 N FULLY 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: Occupancy Dates: Buildines Employees Dormitories from I/o i/ao to ia/.n i/_aQ Crop y SF Dwellings from _/ / to_/ / Crop Apartments Owner Owned ME/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: M i/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive 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. Fee Schedule Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$15.00 each=$ ( 5D. 00 ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ I.ate Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application ^ TOTAL FEE DUE$ pG00,O0 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,TitleIMBADO lifornia Code of Regulations. Applicant Name L A WRENC E Title PRES, �oWJU ES2_ ❑ Partnership (Please PRINT or TYPE) L2CC.rporation Address 90r17N. -FLLLLYL=ND`N A 95@33da Phone&)q.,et31-QS�Q, Applicant Signature Date of Application Amount Paid Date of Payment Payment Type heck/Receipt# Received By Account ID D 12 ,2t 0033238 Facility ID Program Record ID P/E Assigned to PWS ID FA0018722 T PR0527631 2765 0016-HO WA0515744 Report#:7066 Application Printed:1111 3/2 0 1 9