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San Joaquin County-Environmental Health Department <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 P" IV1E1\J y <br /> RF(­11 EI VFL) <br /> APPLICATION i 1 2010 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE 3AN JOAOUIN COUNW <br /> EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTAL <br /> HFAITH%PARTME <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar ear NT <br /> ❑Amended Permit: "Change of Operator "Change of Owner <br /> "Change of Operator Address "Change of Owner Address <br /> "Additional Employees <br /> Permit ID#: 0011914 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this JC21np ID#: 39000370 <br /> Site Name: A SAMBADO&SON 39-370 Location: 15294 E EIGHT MILE RD,LINDEN <br /> Operator: A SAMBADO&SON INC <br /> Mailing Address: 8077 N TULLY RD,LINDEN CA 95236 Facility Phone#:(209)931-2568 <br /> Legal Owner: SAMBADO,LAWRENCE J&BEVERLY New Owner? ❑Yes ❑ No <br /> Owner Address: 8077 N TULLY RD, LINDEN CA 95236 Owner Phone#:(209)931-2568 <br /> Community Facilities Provided by Camp: Community Kitchen 7 ❑ Yes ❑ No <br /> Men: Number of Toilets F�(fj�//(�� Number of Showers Number of Lavatories <br /> Women: Number of Toilets /11410 u JI le7 a Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees <br /> Dormitories front-/---70 /Q ,o _rop <br /> SF Dwellings from _/_/ to_/_! Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 1-52 S0 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: /V'a-1 o0 <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> El Inactive <br /> 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. <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fer $35.00+ Number of Employees i� <br /> _1[/ @$12.00 each=$ /oZ <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Em to ces p y @$24.00 each=$ <br /> Fee must be submitted with Application o <br /> TOTAL FEE DUE$ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1, Part 1, Division 13 of the California Health <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25.California Code of Regulations. <br /> Applicant Name �(1/9 eg P ���//���(0 Title �„/1���7- ❑Partnership <br /> (Please PRINT or TYPE) <br /> �/�, corporation <br /> Address Lr iv. ZI /J tip C Ql v2 3 Phone <br /> Ste¢• <br /> Applicant Signature Date of Application 0 <br /> Amount Paid Date of Payment Payment Type Check/Reeeipt# Received By Account ID <br /> 0023136 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0013764 PR0518217 2765 1�A' WA0515716 <br /> Reoort#:7066.rot /In v #:(- /5 7 Application Printed:10/14/2009 <br />