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VVuyu IIl VU U II Ir No.1 Ub / <br /> inn Joaquin County-Environmental Health Dept', ,,ant <br /> 186o E.Hazelton Avenue-Stockton CA 95205-Phone: 20.9-468-3420 P AYIW <br /> APPLICATION A N o p <br /> E'N{'11iONNIENTALHEALTH O 2Vi j <br /> PERMIT TO OPERATE SAN JOAQUI <br /> kMPLOYEE HOUSING OR t Agog CAMP ENVII� N COU <br /> ❑New Camp []CondlfionN)Permit ❑ Multiple Years(Perntnntnl Rousing camps onl H�ALTf/ �, NTV <br /> ENT'AI_ <br /> I]Amended Permil: 'Change of Operator " p yl lAnnual Permlt for Cnlendxr Ve ART ENT Z��S Change of Owner <br /> "ChHnge of Operator Addreu `Change of Owner Address <br /> Additional Employees Permit ID tl: 0011914 <br /> State ID H: 39-15729-EH <br /> Please Note any Corrections or Changes in Facility/Operalor of ornialion directly on this form. Ell ID h: 39000370 <br /> Site Name: A SAMDADO&SON 39-370/WTR SYS <br /> Location; 15294 E EIGHT MILE kl),LINDEN <br /> Operator: A SAMDADO&SON INC <br /> MnilIngAddremi 8077 N 7ULLY RD,LINDEN CA 95236 <br /> E <br /> onr lF:(209}931-2568Legal Owner: SAMBADO,LAWRENCE J&BEVERLYL\ew Owner 7 Yes NoOwner Address: 8077 N TULLY RD,LINDEN CA 95236Cummunilx Facilift a PYOVId 1 Camm. one M,(209}931-2568 <br /> Community Kitchen? Q Yes No <br /> ,lien; Number of Toilcls Number of Showers <br /> Women: NumberofToilcls Number of5howcrs Number ofLavalories <br /> Number of Lavatories <br /> Dousing Ac ommnrla{{o,c to h Utilized fhis 1 ear. <br /> OccuoancvDates; <br /> i1LLllJlhl�s 'm to- <br /> llorn,ilorics From�1�1�r�,o�� 3l i � <br /> SF Dwellings Crop o 1ec--,* i(_L ' <br /> Apartments from_/ / to /_/ <br /> Crap <br /> Owncr ONned MH/RV Total Number of Days to be used Ibis Calendar Year <br /> O%Vner Owncd kR Cars Tolfll Days Occupied by 25 or awre Employees: , S <br /> 14H/RV Spaces ` <br /> TOTALS Camps occupied by 25 or murc Employees for 60 or murc days in a year <br /> ❑Inactive <br /> L� J t Require a PUIRLtC NVATER SYSTEM Permil <br /> Ymportant: In order to protect your land usn status,if ramp will not be used[his year but Is intended for use in the Cum <br /> rt,,Check this Box and return this application. <br /> Fee <br /> Permanent Camp Annual Permit Fet $35.00+ rr-� ^Number of Ulledule Employees Cal$12.00 each=$ OC�,t✓t� <br /> Q Orchard Camp Pcrntit Fce Number of Employees <br /> ❑ TmnsferofC)N�nership $9aW=$ <br /> ❑ Pemmanent Arncndmer(1 Fee $20.00+ Number of Additional Ern to yecs $20.0o=$ <br /> $70.00+ <br /> ❑ Lale Application Pee P y ©512.00 each=$ <br /> Number oPEmployees (�$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUF S I <br /> Acmit TOTAL FEE as CALCULATED A80VE in the ENCLOSED SCIF-Rdressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <br /> Applicant agrees Io all necessHry inspections incident to lssunncr Of a PERi111T TO OPERATE, Appliranl agrees Iliac this projeel(camp)shall be operated <br /> Hnd maln(ained In aecordxnec rrith the applicable provisions of the E41PLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of The Callfortrin hfeahh <br /> and Safety Code and Chapter 1,Subehapter 3,Tillc 25,California Code ofReguladuru, N <br /> Applicant Name L 1,0.)R ENC E i�LA M B A DD Title(Please PRINT or TYPE) T Porincrship <br /> Address 80 rr U L1— LrN(D Corporation <br /> EA; 14 q _. 3 Phone <br /> Applicant Signature <br /> Date of Application I_ e7— ( ►5 <br /> Amount Paid Dale of Payment Payment Type/ y YP Chat klReceipt q Received By Account Ilb <br /> ( SS //�//.� ✓ 0 Z 0023136 <br /> Facility ID Program Record 10 PIE <br /> FA0013764 Assigned to PWS ID <br /> JyFt0518217 2765 2424-VELOSO <br /> WA051571fi <br /> ReoW g:70M <br />