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Jr S 'oaquin County-Environmental Ilealth Depart, l • 304 E Weber nue-Third Floor-Stockton CA 95202- Phol 09-468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑ Conditional Permit ❑ Multiple fears(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 IU#: 0011914 Please Note am Corrcclions or Changes in Facililr/operator Inforn+nlion 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(honer: SAMBADO,LAWRENCE New Owner? ❑Yes ❑ No Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone tt:(209)931-2568 Community Facilities Provided by Cam • f9rumunit,Kitchen: YcsN Men: Number of Toilets 1.__I Number of Showers Number of lavatories Women: Number of Toilets K1 Number of Showers Number of lavatories _ Housing Accommodations to be Utilized this Year: o Occupancy Dates: Oct— Bttildi� Employees fron "to O Crop Dormitories from_/_/_to_/_/_Crop _ SF Dwellings �r Q Apartments total Number of Days to be used this Calendar Year J Owner Owned MH/RV 'Total Days Occupied by 25 or more Employees 17h t 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 importan(: 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 10 wv Permanent Camp Annual Permit Fee: $35.00+ Number of Employces $12.00 each=$ /s ❑ Orchard Camp Permit Fee: $95.00=S nn Transfer of Ownership: $20.00=S El Late Amendment Fee: $20.00+ Number of Adtlitional Employees nu $12.00 each=S Late Application Fee: $70.00+ Number of Employees G$24.00 each=$ Fee must be ubmitted with Application TOTAL FEE DUE: S � Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope MAKE ClIECKS PAYABLE TO: PHS-EIID Applicanl agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall he operated and maintained in accordance with the applicable provisions of the EMPLOYEE IIOUSING ACT,Chapter 1, Part 1,Division 13 of the California llealth and Safety Code and Chapter 1,Suhchapter 3,Title 25 California Code of Regulations. Applicant Name �(Ao r Q►�'�•C t`-+'��'•6%466o Title P(,Q"Lr ❑ Partnership (Please PRINT or TYPE) *LgCorporation Address �• O dt C • 95A3C PhonQ40*7 - 931-Q,14 F Applicant Signature Date of Application Amount Paid Date of Payment Payment Type ec Receipt# Received By Account ID 4, 1 (O D 3 ✓ � I g' 3 PC 0023136 Facility ID Program Record ID P/E Assigned to PWS ID 0013764 0518217 2755 6916-BORGMAN 0011914 Report#:7066.rot �" Y" 1b;47 / Application Printed 1 1120120 0 2