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Joaquin County-Environmental Health Depart t E� <br /> 600 ain Street-Stockton CA 95202-Phone: 209- j420 PAYM. <br /> APPLICATION U L�.' 3 1 2008 <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <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 FacilityiOperator Information directly on this I Camp 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 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? ❑ Yes ❑ No <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Emplovees L <br /> Dormitories from /y Axe o to VG�/.��� Crop <br /> SF Dwellings _� from / / to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV //1 Totall Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars CX Total Days Occupied by 25 or more Employees: /I OWIC <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 /> ❑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 1, <br /> n <br /> Permanent Camp Annual Permit Fe( $35.00+ Number of Employees 0— @$12.00 each=$ da <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 Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE S <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 zzywxemee . 4,,w Ale Title ❑Partnership <br /> (Please PRINT or TYPE) Corporation <br /> Address 077 Al Zl&anfl, 4W 4L2-34 Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Reeei t# Received By Account ID <br /> 1 \ 2 3 t I l I ` 0023136 <br /> b <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0013764 PR0518217 2 5 1 1 1421 -RIVERA N/A <br /> Report#:7066.rpt Date V Application Printed:10/30/2008 <br />