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41' Joaquin County-Environmental Health Depa, at <br /> 304 E Webt .✓enue-Third Floor-Stockton CA 95202-Phc 209-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <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 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: CorVmunity Kitchen: Yes NILJ <br /> Men: Number of Toilets L41 Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: �I <br /> Buildings Employees from_ _ o_ Crop _ m t/CLt?n/ <br /> Dormitories from_/_/_to_/_/_Crop <br /> SF Dwellings s� <br /> Apartments Total Number of Days to be used this Calendar Year�i <br /> Owner Owned MH/RV Total Days Occupied by 25 or more Employees <br /> Owner Owned RR Cars Note: <br /> MH/RV Spaces Camps occupied by 25 or more employees for 60 or more dans1i a year <br /> TOTALS require a Public Water Systenp) .iIG._--IVT <br /> DECEIVED <br /> ❑ Inactive DEC 2 3 2003 <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 /> SAN JOAQUIN COUNTY <br /> r,lsn,e t=nlTAl <br /> Fee Schedule HEALT EPARTMENT <br /> ❑Permanent Camp Annual Permit Fee: $35.00+ Number of Employees �� @ $12.00 each=$ yi�ss• <br /> ❑ Orchard Camp Permit Fee: $95.00=$ <br /> nn Transfer of Ownership: $20.00=$ <br /> El Late <br /> Amendment Fee: $20.00+ Number of Ad(114ional Employees @ $12.00 each=$_ <br /> Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be Qu mittecl with Application <br /> TOTAL FEE DUE: I S S' V O <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope <br /> MAKE CHECKS PAYABLE TO: PHS-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,California Code of Regulations. <br /> Applicant Name L p,�,J V,e PICX, —C,.A W% �tiO� Title lor,4 ❑ Partnership <br /> (Please PRINT or TYPE) ❑Corporation <br /> Address 0 71 0 G LY Kd L4 6R' �1 SZ 3� Phonc(2v0l) 9 t l 7- 57p <br /> Applicant Signature III Date of Application l?-f,;V7/p J <br /> OE <br /> Amount Paid Date of Payment Payment Type tho&Receipt# Received By Account ID <br /> �_✓ � I� �p � ✓ - ��� 0023136 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> 0013764 0518217 2755 6916-BORGMAN 0011914 <br /> ReDori#:7066.rot Application Printed:11/19/2003 <br />