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Feb-22-05 02:53P C P.06 <br /> San Joaquin County-Environmental Health Department <br /> 304 E Weber Avenue-Third Eioor-Stockton CA 95202-Phone: 209.46S-3420 PAYMENT <br /> RECEIVED <br /> APPLICATION F E e 2 3 2 a vi�l <br /> ENVIRONMENTAL IIEALT14 <br /> PERMIT TO OPERATE SAN JOAQUIN COUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTAL <br /> ❑New Camp ]Conditional Pernttlt ❑ Hultlple Years(Permanent Hausink('amps ouly) ❑Aruunl t'errnil fn'Ca TftltiZE '"J NT <br /> ❑Amtmttd Pennk; 'Change of Uprrutvr 'Chrngr of Owner <br /> "Change of Operator Address 'Change of Owner Address <br /> 'Addiliunal 6:mployrrs <br /> Pcrmtt ID#: 0011914 <br /> Please,Vote any Cnrrections or l'ftmtge's in FrsCi(ity/Operatnr hrfnrn:atinn directly un thi..y Camp Ill#: 39000370 <br /> Site Name: A SAMBADO&SON 39-370 Location: 15294 E EIGHT M LE 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? E]Yes ❑ No <br /> Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone 9:(209)931-2568 <br /> Community Facilities Provided by Cump: Community Kitchen'' ❑ Yes ❑ No <br /> Vlcn: Number ofl'oile(s F12yq, Number of Showers Numbernflavatones <br /> Women: Numherat"frnlets NurnixrofShowers Nurrlbct'OfLa�ateli(S <br /> Houtine Accommodations to be Utilized this Year: Occupancy Pules: <br /> Ruildines F:mnlovccs <br /> Perr111101 IGS tram s._._.__. ...to�.0 ..J1f►'._. ('rnp _ <br /> SI-Dwellings tinm —/---ui-—! / — Clol, ��- <br /> Apartments <br /> Owner Owned MI I/RV Total Number of Days to he used this('alcndar Year: aj o <br /> :)wner Owned RR Cars Total Days Ckcupied by 25 or rrwro Employees: Y1c-rs+-. <br /> ~' MH/RV Spacr:a Note <br /> TOTALS ♦'amps occupied by 25 or more Employees for(A or more days In a year <br /> Require a P1181.IC WATERATER SYSTEM Permit <br /> ❑Inactive <br /> lmportant: In order to protect your land LLw statist,if camp will not be used this year but is intended for use in the future,Check this Box and ictum this application. <br /> Fte Schetlttle /^ <br /> Permanent Camp Annual Permit Fe $35.00+ Number of Employees (J S12,00 t uch-S I A01 <br /> ❑ Orchard Camp Permit Fee S95.1)D-S <br /> ❑ 'rransfer of Ownership S20!w=$ <br /> [�] Femunent Amendment Fee S20,00+ Number of Additional Employees [S12.00 each-S <br /> ❑ Latc Application FCC $70.00+ Number of Employees @$24.00 each=$ <br /> Fee trust be submitted with Application <br /> TOTAL FEE IIUE$ � Sj <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 proAslorts of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,division 13 of the California Health <br /> and Safery Code and Chapter 1,Subchapter 3,Title 25,California Code of Regatari'ans. <br /> Applicant Name ?CG4o �.jp�e� Title ❑Partnership <br /> (♦'leen waNTor TWE? r r Worporattiio-n <br /> Address g 0 7 N 1 J-j nry zi{a� «} q�1 ?3 L Phone <br /> Applicant Signature Date of Application <br /> Amount Pald Date of Payment Payment Type CM ecalpt b Received By Account ID <br /> $ $� ;- a'3/0 J Y 3'7/ 0023136 <br /> Farlliry ID Program Record ID PIE Assigned to PWS ID <br /> FA0013764 PRO518217 2/55 (3910-13ORC-MAN N/A <br /> Report o:7066.fpt 1310 51 Application Prinleo 10/29/2004 <br />