BILLING - Laserfiche WebLink

Home Browse Search

Y ..F San Joaquin County-Environmental Health Department 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3426 L 9 6►�q dWt0 R�jl q 6 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP C'Pr'VlIZONIFN 1'. 1, 11F. I;I Iyi New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Peft[dr`�eX id 1 Y�ft.I' ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Pbrmit ID#: *Additional Employees State ID#: EH ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on this form. Site Name: Clarion Inn Location: 4219 Waterloo,Stockton, CA Operator: Smith Packing, Inc. Mailing Address: 312 E MITI Suite 202, Santa Maria CA 93454 Facility Phone#:X8053571322 Legal Owner: Champ Patel New Owner? ❑Yes No owner Address: 421*9 Waterloo Stockton CA Owner Picone#: 209-931-3131 Communitv Facilities Provided by Cama: Community Kitchen? ❑ Yes IN No Men: Number of Toilets 8 Number of Showers 8 Number of Lavatories 8 Women: Number of Toilets Number of Showers Number of Lavatories Housiny Accommodations to be Utilized this Year: OccuoancyDates: Buildines Employees Donnitories 1 30 from 4 /25/ 21 to 1 /15/22 Crop Tree Fruit SF Dwellings from _/_/ to_/_/ Crop Apartments Owner Owned MH/RVTotal Number of Days to be used this Calendar Year: 250 �la Total Das Occupied b 25 or more Employees: Owner Owned RR Cars Y P Y MH/RV Spaces Note TOTALS 30 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 450 ® Permanent Camp Annual Permit Fee $50.00+ Number of Employees 30 @$15.00 each=$ ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 450 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 m4intained 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 Vernon Smith Title Director ❑Partnership (Please PRINT or TYPE) ®Co oration Address 312 E Mill Suite 202 Santa.-Maria,:CA 93454 Phone 805 357 1322 Applicant Signature •�` '' ' Date of Application 3/12/2021 Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID Facility ID Program Record ID Assigned to PWS ID (�_L) ?)yNIA Report#:7066 Application Printed:3/1012021