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c 'oaquin County-Environmental Health Depart J 304 E Weber -nue-Third Floor-Stockton CA 95202-Phom. 9-468-3420 ^U APPLICATION ii 1 ENVIRONMENTAL HEALTH l �•(� 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 ID#: 0011914 Please Note any Corrections or Changes in Facility/Operator Information directly on this I 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 Cam • Cpmmunity Kitchen: LJ Yes NLJ Men: Number of Toilets 1 I -J Number of Showers Number of Lavatories Women: Number of Toilets K Number of Showers Number of Lavatories _ Housing Accommodations to be Utilized this Year: Occu anc Dates- Buildings 1es: �} Buildings Employees from to OG1 Crop Dormitories from_/_/_to_/_/_Crop SF Dwellings �50 Apartments Total Number of Days to be used this Calendar Year Owner Owned MH/RV Total Days Occupied by 25 or more Employees C Owner Owned RR Cars Note: MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year TOTALS require 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 Fee: $35.00+ Number of Employees O @ $12.00 each=$ bS ' ov ❑ Orchard Camp Permit Fee: $95.00=$ ��'��{{ Transfer of Ownership: $20.00=$ ElPermit Amendment Fee: $20.00+ Number of Adtttlional Employees n $12.00 each=$_ Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ Fee must be Aubmitted with Application ',615/d'a TOTAL FEE DUE: $ 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 1,Subchapter 31 Title 25 California Code of Regulations. Applicant Name L*Ao r @►1 c-< V a Title �(�i, ❑Partnership (Please PRINT or TYPE) %Corporation Address 44 „ 9s434 PhonOQ • 93 L B' Applicant Signature Date of Application 0 Amount Paid ir Date of Payment Payment Type ec Receipt# Received By Account ID f` r O 3 N I g,1/ 3 /-C 0023136 � , o0 Facility ID Program Record ID PIE Assigned to PWS ID 0013764 0518217 2755 6916-BORGMAN 0011914 Report#:7066.rot Application Printed:1112012002