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on Paquin County-Environmental Health Depart% RECEIVED 600 E.Main Street-Stockton CA 95202-Phone: 209- T PVgG FEB Q 8 2012 APPLICATION VED r OiVMENTAL HEALTH EN PERMIT TO OPERATE HEALTH SAN�O`R NME��(yV{R�EtRMIT/SERVICES EMPLOYEE HOUSING OR LABOR CAMP EN M pEPPR ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) H 9 Annual Permit for Calendar Year � ' V ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#: 0005643 *Additional Employees State ID#: 39000321 Please Note any('orrections or Changes in Facility/Operator lnJorinalion directly on dtisJoi•m. 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 2"'No Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone#:(209)931-2568 Community Facilities Provided by Camp:W(:� Community Kitchen'1 ❑ Yes �ff No 1len: Number of Toilets FAMSLY Number of Showers Number of Lavatories Women: Number of'foilets I-Inusx"Gr Number of Showers Number of Lavatories Ilousine Accommodations to be Utilized this Year: Occut)ancv Dates: Buildings Emplovees Dormitories from01 /Q/'01Qto�/�/�Crop CRC H A R,D SF Dwellings from _/_/ to /_/ Crop Apartments Owner Owned MI /RV 1 Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: N ON P MI I/RV Spaces Note TOTALS 15 �5 Camps occupied by 25 or more Employees for 60 or more days in a)'cur Require a PUBLIC WATER SYSTEM Permit ❑Inactive Important: In order to pnxcct_ ur land use status,ifcamp 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 Fel $35.00+ Number of Employees .00 each ❑ Orchard Camp Permit Fee Number of Employees _% $95.00=$ ❑ 1'ranster of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each= ❑ Late Application Fee $70.00+ Number of Employees Q$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUF,$ Rcmit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self- dres. d Envel p ' MAKE CHECKS PAYABLE to EHD gt� Q�1 �1�� 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 Snfetr Code and Chapter 1,Subchapter 3,Title 25 aJifornia Code of Regulations. Applicant Name L•ALoRE/'VC.E i=M8Aon Title PRESXDUJ1" El Partnership release PR/NTor TYPE) t OTpOiahOn Address $�l7 T L Z `-1 3 Phone to IApplicltt Signature Date of AtI— 6 I !Ility nt Paid Date of Payment Payment Type Chec-s/7Receeiiptp# Received By Account ID SS• V �l Z— ✓ S/ Z lO 0003775 ID Program Record ID P/E Assigned to PWS ID 04113 PR0270321 2765 2424-VELOSO-CACAPIT WA0515747 Report#.7066.ru1 Date a B 12 Application Printed:10/25/2011 �� zzl�l�(o�