BILLING - Laserfiche WebLink

Home Browse Search

Joaquin County-Environmental health Departs PAYMENT- 186?) 186a E.Hazelton Avenue-Stockton CA 95205-Phone: 209-4(38-3420 APPLICATION ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT New Camp [:]Conditional Permit Multiple Years(Permanent Rousing Camps only) ❑Annual Permit for Calendar Year Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#• *Additional Employees State ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on this fhrn. EH ID#• Site Name: T—a4e., 4-Rc-d t,c.K-l-:s- Location: i ( �g oS W1A1'�Q. Operator: Em( l&tf TAR04 Ca/V t O'CT-6 Vz ' LL<- h Mailing Address: (-+LJ 5O aq (f_)S AAJ-D S �0,4.�s S CA- Facility Phone#: Legal Owner: 1E :fjNew V��' AlC,re� p�� New Owner? ❑Yes [3-NoOwner Address: (?i{i"j0 yl1J L.S f• +-.S $ad,,�+�Sr U'1- �3 `vT Owner Phone#: Community Facilities Provided by Camp: Community kitchen? ❑ Yes 13"No Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees p c S Dormitories from �/ �/ Zb2lo�/ S/ �� Crop /QG r SF Dwellings from to Crop Apartments 0-0 Owner Owned MH/RV Total Number of Days to be used this Calendar Year: ( 2P Owner Owned RR Cars Total Days Occupied by 25 or more Employees: t 2-D MH/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 Bos and return this application Fee Schedule Q Permanent Camp Amoral Permi'Fee $50.00+ Number of Employees @$15.00 each=$ jP ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee S100.00+ Number of Employees o $30.00 each=$ Fee must be submitted with Application TOTAL FEE DUE Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EIID 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 Coyle and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name LyiS 8c""" Title p yr ❑Partnership (Please PRINT or TYPE) [:]Corporation Address Sa AVA-1i�tf Qsll, q L-s .4.j S�•�tt�noL3 � 0 Phone -'L"-c-r- f 2 Applicant Signature Date of Application 3/q(gaze Amount Paid Date of kwavent Payment Type Check/Receipt# Received By Account ID eC1`- Facility ID Program Record ID PIE Assigned to PWS ID N/A Report#:7066 Application Printed:3/3/2020