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w Joaquin County-Environmental Health Depa lit 304 E Webt /enue-Third Floor-Stockton CA 95202-Pit(, 209-468-3420 APPLICATION F,NVIRONMFNTAI,HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit I#: 0011914 Please Note any Corrections or Changes in Facility/Operator hlformntion directly on this Camp 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? ❑Yes ❑ No Owner Address: 8077 N TULLY RD, LINDEN CA 95236 Owner Phone#:(209)931-2568 Community Facilities Provided by Camp: Corgmunity Kitchen: YesN Men: Number of Toilets ,L41 Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories 1lousine Accommodations to be Utilized this Year: Oc c up anc vDates: Buildings Employees from_ _ o_ Crop _ m ✓CA, Dormitories from_/_/_to_/_/_Crop _ SF Dwellings S� Apartments Total Number of Days to be used this Calendar Year�i Owner Owned MH/RV Total Days Occupied by 25 or more Employees Owner Owned RR Cars Note: MH/RV Spaces Camps occupied by 25 or more employees for 60 or more dayys' a year TOTALS require a Public Water SysterpAYIMEIM RECEIVED ❑ Inactive DEC 2 3 2003 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. SAN JOAQUIN COUNTY ��lii nr.uAt=wlTAl Fee Schedule n HEALTH pEPARTMENT ❑Permanent Camp Annual Permit Fee: $35.00+ Number of Employees f% a@ $12.00 each=$ �$,i�7�• f�t� ❑ Orchard Camp Permit Fee: $95.00=$ nn Transfer of Ownership: $20.00=$ ❑ Permit Amendment Fee: $20.00+ Number of ALgional Employees (7a $12.00 each=$_ Late Application Fee: $70.00+ Number of Employees rd$24.00 each=$ Fee must be LInnitted with Application TOTAL FEE DUE: $ 4 (S S' o C) Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope MAKE CHECKS PAYABLE TO: PHS-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 I,Subchapter 3,Title 25,California Code of Regulations. Applicant Name La,.j tre-pic , $.pvv✓t 6ti,p o Title Pre& ❑ Partnership (Please PRINT or TYPE) El J / Corporation Address (Sa7") (.Ly K L4 � of sZ36 PhonQvol) i � l — ?- Applicant Signature Date of Application 12-fa•7/p•_; Amount Paid Date of Payment Payment Type /Receipt# Received By Account ID 9 -3lI 0023136 Y / Facility ID Program Record ID P/E -7 Assigned to PWS ID 0013764 0518217 2755 6916-BORGMAN 0011914 Report#:7066.rot I Ir ,/ 4 / I q Application Printed: 11/19/2003