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oaquin County-Environmental Health Departs. 600 E.Main Street-Stockton CA 95202-Phone: 209 (�IE E�RECEIVED 6 IN APPLICATION `G�,{J V COVN� ENVIRONMENTAI.IIF.AL'TII SON 30p,ONME �6fRONMENTAL HEALTH PERMIT TO OPERATE ENS POD EMPLOYEE HOUSING OR LABOR CAMP H�nN DE PERMIT/SERVICES ❑New Camp []Conditional Permit ❑ Multiple Years(Permanent(lousing 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#• 0011914 *Additional Employees State ID#: 39000370 EH ID#: 39000370 Please Note arty Corrections or Changes in l acilitv.%Operalor Information directly on tlusform. 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 a No Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone#:(209)931-2568 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Ilousine Accommodations to be Utilized this Year: Occunancy Dates: Buildines Employees Dormitories from t3 /�I /aolalo(a/31 /MG-Crop SF Dwcllin-s �— from _/ / to_/_/� Crop Apartments (teener Owned�RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MI I/RV Spaces Note TOTALS �� Camps occupied by or more Employees for 60 more days in a year L; 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 Permanent Camp Annual Permit Fet $35.00+ Number of Employees a $12.00 each=$ 1 Q0,00 ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transter of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees a $12.00 each=$ ❑ Late Application Fee $70.00-+- Number of Employees a $24.00 each=$ Fee must be submitted with Application 'TOTAL FEE DUE S I ss, 00 0/ 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 EAfPLOVEF. IIOUSING ACT,Chapter 1,Part 1, Division 13 of the California Health rrnd Safety Codc and Chapter 1,Subchapter 3,Title 25 lifornia Code of Regulations. Applicant Name L,(�(1) CAI("- AMBADCp Title PRES- = DE&T Partnership (Please PRINT or TYPE) Corporation Address �Np N q Phone q - 8 kpplicant Si,-,nature Date of Application Amount Paid 7�_P; yment Payment Type Check/ ceipt# Received By Account ID L ( �— 57� 0023136 Facility ID Program Record ID PIE Assigned to PWS ID FA0013764 PR0518217 2765 2424-VELOSO-CACAPIT WA05157161 Report#:7066.rot Date I z Application Printed:1 012 512011