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f oaquin County-Environmental Health Depar t r 304 E NN eber avenue-Third Floor-Stockton CA 95202-Phon.. 109-468-3420 f-;'��-�,�., •.�',;l,. APPLICATION 3 S lQ(j; ENVIRONMENTAL HEALTH �O<IQU//y 0 PERMIT TO OPERATE H�UV IRONtL1Ef�0UIV 7, EMPLOYEE HOUSING OR LABOR CAMP N DEp rA� ART/yE E]New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year NT ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: 0011914 Please Note any Corrections or Changes in Facility/Operator Information directly on this JCamp ID#: 39000370 Site Name: A SAMBADO&SON 39-370 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 New Owner? E]Yes ❑ 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 /G Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housin2 Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories from "whiedh to 6/M&Aw Crop SF Dwellings from _/_/ to_/_/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: .2S-0 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: A/4041E MH/RV Spaces Note TOTALS Camps occupied by or more Employees for 60 more days in a year 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 /0 @$12.00 each=$ ❑ Orchard Camp Permit Fee $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees (a7,$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ /$S 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 EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name � Ly/�J/J/fp ,�mhAaa Title p�q/,��. ❑Partnership (Please PRINT or TYPE) Corporation Address /y� �/ Q{O Phone Applicant Signature Date of Application Amount Paid L Date of Payment Payment Type Chec erp # Received By Account ID / n\SS q '\ ` 0 0023136,I U Facility ID Program Record ID PIE Assigned to PWS ID FA0013764 PR0518217 2755 6916-BORGMAN N/A Report#:7066.rot U A•I Application Printed:11/17/2005