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PAYMENT 186841aquin County-Environmental Health Depa RECEI VEp "'Iton Avenue-Stockton CA 95205-Phone: 20y-468-3420 DEC APPLICATION SAN JOAQUIN COUNT ENVIROENVIRONMENTAL HEALTH HEALTH DEPARTMENT NT PERMIT TO OPERATE ARTME EMPLOYEE HOUSING OR LABOR CAMP ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year <9a as ❑ Amended Permif: *('hinge of Operalm *Change of ONcner *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 thisform. 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 TUL I_Y RD, LINDEN CA 95236 Owner Phone#:(209)931-2568 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets r 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 Em Ip ovecs Dormitories from /�/�,�to i a-/-3t QQ Crop 051 SF Dwellings from _/_/ to_/ / Crop Apartments Owner Owned MH/RV 1 r1 _ Total Number of Days to be used this Calendar Year: 3 10 5 Owner Owned RR Cars 1� Total Days Occupied by 25 or more Employees: N e)N F— MH/RV Spaces Note TOTALS I� � 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 Fee $50.00+ Number of Employees 1�� @$15.00 each=$ a;1 5. 0 0 ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees a $15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application �y TOTAL FEE DUE$ 2, /5, on Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to 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 3,Title 25,California Code of Regulations. Applicant Name LA w R ENC E 0,1AM BARD Title �CJ O(��ER `❑,Partnership (Please PRINT or TYPE) L21 Corporation Address $or77 . TuLLY D. . L=Nbc A 9-6a31Q Phone aog- 93l—DP( 6 Applicant Signature Date of Application Amount Paid Date of Payment Payment Type aec Receipt# Received By Account ID 0003775 Facility ID Program Record ID PIE Assigned to PWS ID FA0004113 PR0270321 2765 3611 -GIRARDI WA0515747 Report#:7066 Application Printed:12/2/2021