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• I Joaquin County-Environmental Health Depat it PAYMENT <br /> 600'L.Main Street-Stockton CA 95202-Phone: 209-468-3420 RECEIVE[) <br /> APPLICATION "'AN JOAQUIN Oi)U <br /> ENVIRONMENTAL HEALTH �IRON"EM <br /> PERMIT TO OPERATEHEALT O� AL <br /> ARTNEW <br /> EMPLOYEE HOUSING OR LABOR CAMP n <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year `00 <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#: 39000321 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> 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 Ot�net-Phone#:(209)931-2568 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes 19 No <br /> Men: Number of Toilets 0,2 VV% Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occunancy Dates: <br /> Buildings Employees <br /> Dormitories from Q 1 / 01/�_to 10L/31/ 03 Crop <br /> SF Dwellings /� from _/_/ to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV 1 l Total Number of Days to be used this Calendar Year: 36,j <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: NONE <br /> MH/RV Spaces NQU <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 15 +, <br /> Permanent Camp Annual Permit Fet $35.00+ Number of Employees @$12.00 each=$ 1 QO. 00 <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 (j <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 alifornia Code of Regulations. <br /> Applicant Name LP.wREAIC� MMBAD0 Title PRESTT)ENT [I Partnership <br /> (Please PRINT or TYPE) ^�-� Corporation <br /> Address �l t�t v, 1 L L=N m C, rj A Q 3 Phone Q0q q3 —QJC- LE <br /> Applicant Signature Date of Application -T � <br /> Amount Paid Date of Payment Payment Type `Check/Receipt# Received By Account ID <br /> #/55 D—& Ve (! g 76 9 64y <br /> 0003775 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0004113 PR0270321 2765 2424-VELOSO-CACAPIT WA0515747 <br /> Loggea <br /> Report#:2bF).rpt pate . ,% k9j Appiic:a Printed.i ii ii2u i2 <br />