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Feb-22-05 02 : 53P P. 06 <br /> San Joaquin County-Environmental Health Department <br /> 304 E'A cber Avenue-Third floor-Stockton CA 95202-Phone: 20944S-3420 PAYMENT <br /> RECEIVED <br /> APPLICATION E B 2 3 <br /> ENVIRONMENTAL REALT" <br /> PERMIT TO OPERATE SAN JOAQUIN COUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMEENTTA <br /> . AL❑ Ncw Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing(aims nrdv) El AnnualPtrmir fn Ca�r�L�Hlrl�""J <br /> ❑ Amemletl Permit. Change of Operator Chrtnge of Clwptr <br /> "Change of Operator Address 'Changc of Owner Address <br /> *Adt ilhwal Em ployrrs <br /> Permit ID#: 0011914 <br /> Please Noce air),Correclinnr nr Chnnges u-Facility✓Operatnr Ir jrnrzatinn directly un 0"V Camp IU#: 39000370 <br /> Site Narne: A SAMBADO&SON 39-370 l.ncation: 15294 E EIGHT M LE RD, LINDEN <br /> Operator: A SAMBADO&SON INC <br /> Mailing,Address: 8077 N TULLY RD,LINDEN CA 95236 Facility Phone4:(209)931-2568 <br /> Legal Uwncrr SAMBADO,LAWRENCE Ncw 0-ner? ❑Yes ❑ No <br /> Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone 4:(209)931-.1568 <br /> Community Facilities Pruvided by Cump: Community Kitchen? ❑ Yes ❑ No <br /> Mcn: Numbrr ut]bileus Q Vh t Number of Showers Number nt'Lavatom s <br /> Women: Numhcrof"I'rokts NurrlberufShu,wrrs Nurrlbcr'u(il�atoiikS <br /> Musing Accommodations to he Utilized this Year. Occupancy Dulls' <br /> RuildiuEs F.mnlavee <br /> 51'Dwellings ti ml, _/_— Ii,---t—/------ C-1r <br /> Apartments <br /> Owner Owned M I I/RV Total Numher of[lays to hC used this Calendar Year: �5 0 <br /> 7wner Owned KR Curs 7oml Days Occupied by 25 or more Employees' <br /> 4 MH I RV Spaces Note <br /> TOTALS Camps occupied by 2$or more Employees for 60 or more days in a year <br /> Require a PUBI.1C WATER SYSTEM Permit <br /> ❑Inactive <br /> Important: In order to protect ynur land u.L'_slams,if camp will not be used this yea;but is intended for use in the future,Check this Box and ictum this application. <br /> Etc Sstlt(1_kjl_c /^ <br /> Permanent Camp Annual Permit Fe $35.00+ Number Of Employees S12.00 ruch-S I A01 <br /> ❑ Orchard Camp Permit Fee S95.00-S <br /> © fransfer of Ownership S20.,X)=$ <br /> C1 Permanent Amendment Fee S2000+ Number of Additional Employm @4$12,00 each-S <br /> ❑ htc Application FCC $70.00+ Number of Employees @$74.00 each=S <br /> Fee must be submitted with Application <br /> TOTAL FEE LUE$ <br /> Remit TOTAL FEE a CALCULATED ABOVE in the ENCLOSED Self-■dressed Envelope <br /> MAKE CHECKS PAVABLF to ERD <br /> Applicant agrees to all necessary inspections incident to Issuance of a PERMIT TO OPERATE. Applicant agrees that this p roject(camp)shall be operated <br /> and maintained in accordance with the applicable provislon.1 of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health <br /> and Safety Code and Chapter 1,Suhehapter 3,Title ZS,California Code of Regulations. <br /> Applicant Name L,T.�C�Y1Gt� ��4j a Title ❑Partrrctship <br /> (Plwse PRINT or TYPE) jCgrpotntipt <br /> Address 0 7n&L, (,A RS Z 3( Phone <br /> Applicant Signature Date of Application 14 <br /> AmOunt Paid Date or Payment Payment Type C eoaipi X Received By Account ID <br /> 002313ti <br /> Y5-37`/ <br /> Facility If) Propeam Record 10 PIE Assigned to PWS ID <br /> FA0013764 PRO518217 2I5S (i910-BORCMAN WA <br /> Reaort tt 7066 rot Applicaticn Prinreo 1012912004 <br />