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S. aaquin County-Environmental Health Departs. PAYMENTRECEIVED600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 DEC ' 0 2ot3 APPLICATION SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ENVIROMENTAL PERMIT TO OPERATE HEALTH DEPARTMENT EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ®Annual Permit for Calendar Year Z� ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#• 0005643 *Additional Employees State ID#: 39-0321-EH Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000321 Site Name: A SAMBADO&SON 39-321 Location: 14000 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 J&BEVERLY New Owner? ❑Yes No Owner Address: 8077 N TULLY RD, LINDEN CA 95236 Owner Phone#:(209)931-2568 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes E� No Men: Number of Toilets F-WnI.L Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories from 0 t / 01/ I4 to 1 c1/31/.14 Crop 0116 A SF Dwellings Z Z from _/_/ to / / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: NO N E MH/RV Spaces Note TOTALS l C, Camps occupied by 25 or more Employees for 60 or more days in a year 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 Fec $35.00+ Number of Employees (Q a $12.00 each=$ QO.06 ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees a $12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees tt,$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ I 5 5.DD Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope t9'I� MAKE CHECKS PAYABLE to EHD 4-0 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 3,Title 25,California Code of Regulations. Applicant Name LALOR ENCE 28M BADn Title —PR E51--QU -' ❑Partnership (Please PRINT or TYPE) Corporation Address GOr7r7 N,-FULLY PD. . L=NDF—N' CA. C1 sa o Phone 6 20A 931-Q5408- Applicant Signature Date of Application ` Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID `SS • �t7 �z�3 e) 0003775 7FAFacility ID Program Record ID PIE Assigned to PWS ID 0004113 PR0270321 2765 2424-VELOSO-CACAPIT WA0515747 Report#:7066 Application Printed:10/17/2013