Laserfiche WebLink
Joaquin County on Environmental Health Departmek,. <br /> 1868 E. Hazelton Avenue - Stockton CA 95205 - Phone: 209468.3420 P A41CfV 7- <br /> ,� <br /> � <br /> APPLICATION FEB 0 3 2021 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE SAN JOAQ111N COU <br /> EMPLOYEE HOUSING OR LABOR CAMP It NWRO NTY <br /> ❑ New Camp ❑ Conditional Permit ❑ Multiple Years (Permanent housing Camps only) ❑ Annual Permit foE4 TAV"; EN Tq L <br /> ❑ Amended Permit: *Change of Operator *Change of Owner �ri' <br /> *Change of Operator Address *Change of Owner Address Permit ID #: 0027815 <br /> *Additional Employees <br /> State ID He <br /> EH IDM <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on thisform. <br /> Site Name: BONNIE PLANTS Location : 23975 E MILTON RD, LINDEN <br /> Operator: DE LA MADRID, MIGUEL <br /> Mailing Address: 23975 E MILTON RD, LINDEN CA 95236 Facility Phone #: (619)664-6921 <br /> Legal Owner: DE LA MADRID, MIGUEL New Owner ? ❑ Yes ❑ No <br /> Owner Address: 23975 E MILTON RD, LINDEN CA 95236 Owner Phone M (619)664-6921 <br /> Community Facilities Provided by Camo• Community Kitchen ? ❑ Yes ❑ No ' 1 <br /> Men: Number of Toilets Number of Showers of Number of Lavatories "I <br /> Women : Number of Toilets Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this War: Occunoncy Dates: <br /> Buildinp„Is Employees <br /> Dormitories from _/ / to _/ / Crop <br /> SF Dwellings from / / to _/ / Crop <br /> Apartments <br /> Owner Owned MH / RV Total Number of Days to be used this Calendar Year: logo <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH / RV Spaces <br /> N� <br /> TOTALS 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 ScheduleRo"Is ( J Ou <br /> Permanent Camp Annual Permit Fee $50.00 + Number of Employees @ $ 15 . 00 each = $ t <br /> ❑ Transfer of Ownership $25.00 = $ <br /> ❑ Permanent Amendment Fee S25000 + Number of Additional Employees @ $ 15.00 each = $ <br /> ❑ Late Application Fee $ 100, 00 + Number of Employees @ $30.00 each = $ <br /> Fee must be submitted with Application 2A O t1 , <br /> TOTAL FEE DUE $ t <br /> SmEhIIIIIIIIN <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 <br /> and Safety Code and Chapter 1 , Subchapter 3, Title 25, California Code of Regulations. <br /> Applicant Name �� /� t v Q e, t, G r I 1 Title 1 Dir^ OVt �✓ <br /> Pp 1 y ` ,�j l (Jl � VA &A ,(d Q b� L Vv ► G'� ❑ Partnership <br /> (P/Base PRINT 6r TYPE) I ( ' + PP p, ❑ Corporation <br /> Address 'L �jCIO: � , LtV� aev� Ci � �Sd- 3 Phone 6L4 ot <br /> Applicant Signature Date of Application i3 <br /> Amount Paid Date of Paym nt Payment Type Check/Receipt # Received By Account ID <br /> zqoa� a 3 i J l 0050073 <br /> 114IgS <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0026344 PRO546475 2765 987 - SANGALANG NIA <br /> � Zo6972 <br /> Report #: 7066 Application Printed : 2/312o21 <br />