BILLING - Laserfiche WebLink

Home Browse Search

_oaquin County-Environmental Health Depar. -_.t PAYMENT 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 RECEIVED UEC J APPLICATION ENVIRONMENTAL HEALTH SAN JOA©UIN COUNTY PERMIT TO OPERATE ENVIRO`uIENTAL EMPLOYEE HOUSING OR LABOR CAMP HEALTH DIEPARTMENT ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar Year `t ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID 4: 0000040 *Additional Employees State ID#: 39-0054-EH Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000054 Site Name: LINDEN ORCHARDS 39-54 Location: 21100 E FRAZIER RD, LINDEN Operator: A SAMBADO&SON Mailing Address: 8077 N TULLY RD, LINDEN CA 95236 Facility Phone#:(209)931-2568 Legal Owner: BOGGIANO FAMILY INTEREST New Owner? ❑Yes No Owner Address: 7899 N DE MARTINI LN, LINDEN CA 95236 Owner Phone#:(209)931-3086 Community Facilities Provided by Camp: Community Kitchen? ® Yes ❑ No Men: Number of Toilets Number of Showers Number of Lavatories LP Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories I from Q t /Qf/ 14 to i2_/,3L/_I_q_ Crop n(XJ1 � SF Dwellings from / / to / / Crop Apartments Owner OwneGM /RV 2 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 QQ Permanent Camp Annual Permit Fe( $35.00+ Number of Employees @$12.00 each=$ a .100 ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees a $24.00 each=$ Fee must be submitted with Application TOTAL FEE DLJE$ `a M,QO 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 L.A W R EN C E GAM BADD Title PR ESZ.DEI')T Partnership (Please PRINT or TYPE) —�- /I Corporation Address gdr(!7 N. { IJ-LLY D. _ LmrjoE i ,01A . g5QS� Phone (a0q)q�1-asgs pj Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID a-7 5 . 12 ,1 t Ll-1-)1-4 �snt� 0000031 Facility ID Program Record ID P/E Assigned to PWS ID FA0000031 PR0270054 2765 2424-VELOSO-CACAPIT WA0515762 Report#:7066 Application Printed:10/17/2013