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•juin County-Environmental Health Departi.. 6001 E.11 Street-Stockton CA 95202-Phone: 209 (y DRECEIVED AF G1Gk — [f8 r CD 08 2012 APPLICATION ! 0V\N COVN� ENVIRONMENTAL IIEALTII 30P a #iONMENTALHEALTH PERMIT TO OPERATE SA��NV1ROEpPR PERMIT/SERVICES EMPLOYEE HOUSING OR LABOR CAMP _ , ❑New Camp ❑Conditional Permit ❑ hlultiple fears(Permanent Housing Camps only) �Plnnual Permit for Calendar Year ❑Amended Permit: *Change or Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#: 0011914 *Additional Employees State ID#: 39000370 EH ID#: 39000370 Please;Vold nav Correctiolls or Changes Ili h-ciedilY,0peralor hijbrnuntion directly on thisjbrnl. 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 Owncr Address: 8077 N TULLY RD, LINDEN CA 95236 Owner Phone#:(209)931-2568 Conlmunit Kitchen'? Yes No ('ommanity Facilities Provided by Camp: UON5 Y Men: Number of Toilets Number of Showers Number of Lavatories Wornen: Number of•Toilets Number of Showers Number of Lavatories Ilousina Accommodations to be Utilized this Year: Occuaancv Dates: Buildings Emplovccs Dormitories fro,I o 1 /o l /aol ato t a/31 /aot a Crop o r G I(L O_r j s SF Dxcellin=s I — I from _/_/_ to_/_/ Crop Apartments / C Owner Owned MI RV Total Number of Days to be used this Calendar Year: 310 5 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: h11 l/RV Spaces Note TOTALS TAt S I .J Camps occupied by or more Employees for M more days in a year L_!J Requiree 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 Permanent Camp Annual Permit Fe( $35.00+ Number of Employees (r $12.00 each=$ v ❑ Orchard Camp Permit Pee Number of Employees $95.00=$ ❑ Transtcr of ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees y,$12.00 each=$ ❑ Late Application Fee $70.00 i Number of Employees Cct>.$24.00 each=$ Fee must be submitted with Application oO � "1.OTAL F'EF.DUE S Remit TOTAL FEE as CALCULATED ABOVE in the I?NCLOSED Self-ad sled Envelope d 6�3� � a S bLr ty MAKE CHECKS PAYABLE:to EIID �6 l/7— f�Dl �+ to Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintainer) in accordance with the applicable provisions of the EMPLOYEE: HOUSING :�C 1,Chapter 1, Part 1, Division 13 of the California Health and Safety Cole anti Chapter 1,Subchapter 3,•title 25 lifornia Code of Regulations. j'� Applicant Name L AI )F_it � GAM BADO Title PR ST l�DE7 Partnership (Please PRINT or TYPE) Corporation Address LAN D EN q 5QLatp Phone Laiq - a Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Checkl ceipt# Received By Account ID 0023136 �� Ss.o J 4'1� z- ✓ 57�9� � Fa Elili y r1r Pr m eco ard ID PIE Assigned to PWS ID FA0013 PRO518217 2765 2424-VELOSO-CACAPIT WA0515716 l - LMeu Reo #:7 �VR Date 7 1 a Application Printed:10/25/2011