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Joaquin County-Environmental Health Depar it 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 P`�YMENT Rece itirzo APPLICATION N ENVIRONMENTAL HEALTH Sq/r J +,, 13 PERMIT TO OPERATE ENYIRp UIM co�N EMPLOYEE HOUSING OR LABOR CAMP HEq� o FgRTv PT ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID 9: 0011914 *Additional Employees State ID th 39000370 Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000370 Site Name: A SAMBADO&SON 39-370/WTR SYS Location: 15294 E EIGHT MILE RD, LINDEN Operator: A SAMBADO&SON INC Mailing Address: 8077 N TULLY RD, LINDEN CA 95236 Facility Phone#:(209)931-2568 Legal Owner: SAMBADO,LAWRENCE J&BEVERLY New Owner? ❑Yes No Owner Address: 8077 N TULLY RD, LINDEN CA 95236 Owner Phone#:(209)931-2568 Communitv Facilities Provided by Camp: 001ji 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: Occupancy Dates: Buildings Employees Dormitories from Q /Q/3_to I(+Z/31/ 13 Crop f,7 fZ 0 Of< W SF Dwellings I from /_/ to_/_/ Crop Apartments Owner Ownede/RV Total Number of Days to be used this Calendar Year: 316� 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 Retluire a PUBLIC WATER SYSTEM Permit ❑Inactive Important: In order to protect your land use status,if camp mll not be used this year but is intended for use in the future,Check:his Box and return this application Fee Schedule n� Permanent Camp Annual Permit Fet $35.00+ Number of Employees (a),$12.00 each=$ l QD•00 ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees C$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees (Q�$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUES 15S.00 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 RE/UC F 2AM BADC9 Title PR FS=,DFIVT' ❑ Partnership (Please PRINT or TYPE) Corporation AddressN. TUL Q Phone(&o�)qq I—as(c,8 Applicant Signature D ate of Application Amount Paid C Date of Payment Payment Type Check/Receipt# Received By Account ID 4/6 3-, 0Z) 13 (�1, __ l� 6474 0023136 E7Facility ID Program Record ID �- PIE Assigned l Assigned.to PWS ID 0013764 PR0518217 2765 24 ++ O-CACAPIT WA0515716 Report#:26FI.rpt Application Printed: 11/1/2012