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PAYMENT <br /> Joaquin County-Environmental Health Depart_ A RECEIVED <br /> E.Main Street-Stockton CA 95202-Phone: 209-468-3420 <br /> DEC 30 2013 <br /> APPLICATION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH ENVIROMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <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 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 /> Owner Address: 8077 N TULLY RD, LINDEN CA 95236 Owner Phone#:(209)931-2568 <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 jDr <br /> UOQ_ Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occunancv Dates: <br /> Buildings Employ _n <br /> Dormitories from C 1/ 01/ 14 to 19 / /�� Crop o3t4cplL m <br /> SF Dwellings from _/_/ to Crop <br /> Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: a sr) <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: N of E <br /> MH/RV Spaces ailic <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 <br /> Permanent Camp Annual Permit Fee $35.00+ Number of Employees ('� @$12.00 each=$ QQ-ob <br /> ❑ Orchard Camp Permit Fee 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 /> XI 1Ja� � 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 and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name LAwR EP ICE 2AM BADn Title PRES=pEAV- ❑ Partnership <br /> (Please PRINT or TYPE) MCorporation <br /> Address GOr77 N T'u.LLY RD. L=NDEN, CA, C1 SQ-1yp Phone Capg g3r-�51,7� <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment ``Payment Type Check/Receipt# Received By Account ID <br /> 0003775 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0004113 PR0270321 2765 2424-VELOSO-CACAPIT WA0515747 <br />