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Joaquin County-Environmental Health Depar t PAYMENT <br /> 600,,.�vlain Street-Stockton CA 95202-Phone: 209- -3420 RF(`FI\/FD <br /> APPLICATION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH ENVIRONMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <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 Facility/Operator 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_ ❑ NQ- <br /> Men: Number of Toilets �L Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees M,� <br /> Dormitories from !! We,* to__AgJ:?,r40� Crop <br /> SF Dwellings from _/_/ to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: o�76V <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: AIVAIF <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 ' T <br /> Permanent Camp Annual Permit Fe( $35.00+ Number of Employees �_ @$12.00 each=$ ��1/ <br /> ❑ Orchard Camp Permit Fee $95.00=$ <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$ <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 alif/ornia_C/ode of Regulations. <br /> Applicant Name �a�j�e/J�10 i7Q�l� Title �/C �ll L ❑Partnership <br /> (Please PRINT or TYPE) // B-ebrporation <br /> Address f�'17 Of4 Z/Wolow z/ Phone R3/ _= SfoJ-1 <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/ ceipt# Received By Account ID <br /> D r0-7 ✓ S�a-37 0023136 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0013764 PR0518217 2755 2089-SOOD N/A <br /> Report#:7066.rpt mot'vv Application Printed:10/18/2007 <br />