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S jaquin County-Environmental Health Departi. <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 PF�'1 hiEhT <br /> RECEIVED <br /> APPLICATION OCT 3 12016 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE SAN JOApUiN COUNTy <br /> EMPLOYEE HOUSING OR LABOR CAMP 'A��N L-H 0 NMENTAL <br /> HEA DEPAR <br /> i� New Camp E]Conditional Permit E] Multiple Years(Permanent Housing Camps only Annual Permit for Calendar Year 1 7 <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#: 0005643 <br /> *Additional Employees <br /> State ID#: 39-0321-EH <br /> Please.Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000321 <br /> Site Name: A SAMBADO&SON 39-321 Location: 14000 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 J&BEVERLY New Owner? ❑Yes No <br /> 77 TU n i v RD LIB:v`E 0523� '_p)no1 '558 <br /> vrr ucr.Audi css: 0, N ,.,��� i.v, ti CA v::uer Piim�e n:(2 lo...-c,. <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes No <br /> Men: Number of Toilets F Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> IlousinE Accommodations to be Utilized this Year: Occuuancy Dates: <br /> B it in Em Ip ovees � <br /> Dormitories from 0 1 /(3 -y(/ 1'/ to l/3(/ 7 Crop ahc <br /> SF Dwellings from _/_/ to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3(prj <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: W)/� <br /> 41H/RV Spaces Note <br /> TOTALS © © Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <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 /> Fee Schedule I&,ru <br /> Permanent Camp Annual Permit Fet $.34..eo+ Number of Employees r @$J2-.Weach=$ a Q 5. <br /> Orchard Camp Permit Fee ` °Ct Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ Late.Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to 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-AWR EN F A M 15ADQ Title PO ESz DFNT o tRE] Partnership <br /> (Please PRINT or TYPE) Corporation <br /> Address M _ 9 Q Phone Caog 4R l_ aTj61; <br /> Applicant Signature Date of Application (In —;:3 <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 70 — ID l3t h �' 1/ _& l'l>° / tj UJ 0003775 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0004113 PR0270321 2765 8987-SANGALANG WA0515747 <br /> Report#:7066 Application Printed:10/13/2016 <br />