BILLING - Laserfiche WebLink

Home Browse Search

F oaquin County-Environmental Health Depart J 1868 E.hazelton Avenue-Stockton CA 95205-Phone: 20,68-3420 PAYMENT APPLICATION ENVIRONMENTAL HEALTH JUN o 2022 PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP SAN JOAQUIN CO ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual]OAK, Amended Permit: *Change of Operator *Change of Owner ]OAK, L I fUEPARTMENT *Change of Operator Address *Change of Owner Address Permit ID#: 0027507 *Additional Employees State ID#: EH ID#: Please Note any Corrections or Changes in Facility/Operator Inrormation directly on this form. Site Name: BARRERA MALDONADO PROPERTIES LLC Location: 1108 ROSEMARIE LN,STOCKTON Operator: BARRERA,LUIS Mailing Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Facility Phone#:(831)272-3523 Legal Owner: BARRERA, EDGAR New Owner? ❑Yes ❑ No Owner Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Owner Phone#:(831)272-3523 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: OccuRaancy Dates: Buildings Employees Dormitories from / 1 to_/_/ Crop SF Dwellings from _/ / to_/_/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 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 Box and return this application. Fee Schedule ❑ Permanent Camp Annual Permit Fee S50.00+ Number of Employees @$15.00 each=$ ❑ Transfer of Ownership $25.00=$ Permanent Amendment Fee $25.00+ Number of Additional Employees �� @$15.00 each=$ 1 ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each-$ Fee must be submitted with Application TOTAL FEE DUE$ �� S ��— 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,California Code of Regulations. Applicant Name Lv�s 1 r ry - Title W eA!2f� r• ❑ Partnership (Please PRINT or TYPE) ❑Corporation Address 1 I q&D (/4 Tele-7Phone g�?(" ),2-01 ' 011�7g2)- Applicant Signature / Date of Application &-,5- �( Amount Paid ate of Payraen Payment Type heckl eceipt# Received By Account ID 1 c�;, 0049219 l � a Facility ID Program Record ID PIE Assigned to PWS ID FA0025974 PR0545931 2755 9834-SUSZYCKI N/A Report#:7066 Application Printed:5/24/2022