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Joaquin County-Environmental Health Depart i RECEIVED 600 L. Main Street-Stockton CA 95202-Phone: 209- 1 V E1E0 FEf3 0 8 2012 APPLICATION FEB iRONMENTAL HEALTH ENVIRONMENTALPERMIT TO OPEIRATE EALI H �oAaN��E�RMIVSERVICES EMPLOYEE HOUSING OR LABOR CAMP _fN1 06p�, ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent(lousing('amps only) H ❑Amoral Permit for Calendar Year ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID 9: 0005643 *Additional Employees State ID#: 39000321 Please Note arty Corrections or Changes in Facility/Operator Information directly on this for•nr. 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 [t'No Owner Address: 8077 N TULLY RD, LINDEN CA 95236 Owner Phone#:(209)931-2568 Community Facilities Provided by Camp: Community Kitchen'? ❑ Yes ❑ No Men: Number of Toilets FAMSLY Number of Showers Number of Lavatories Women: Number of Toilets Ho( sx"G• Number of Showers Number of Lavatories Ifousing Accommodations to be utilized this Year: Occupancy Dates: Buildings Employees Dormitories from0 I /o I_/_@01' o(a/3 Q_Crop OR,C,H A D SF Dwellings from _/_/ to_/_1 Crop Apartments Owner Owned MI1/RV13 Total Number of Days to be used this Calendar Year: _a SO _ Owner Owned RR Cars "fotal Days Occupied by 25 or more Employees: E MI /RV Spaces Note TOTALS 15 Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SVSTEIII Permit ❑Inactive Important: In order to protec r 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 Fe( $35.00+ Number of Employees O 1$12.00 each=$ I J_0.GG ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ l'ransfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees (ii?$12.00 each=$ ❑ 1 ale Application Fee $70.00+ Number of Employees ()$24.00 each=$ Fee must be submitted with Application 'DOTAL FEE DUES 155.Od 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 I, Part 1, Division 13 of the California/lerdrh and Safety Corte and Chapter 1,Subchapter 3,'Title 2S a ornia Code of Regulations. Applicant Name LAw R Ij/VCE oZhm 8 Rom' Title ES=D F��' El Partnership (Please PRINT Of TYPE) Corporate on Address S0(7 T L_ Z q5a'310Phone Applicant Signature Date of Application Amount Paid Date of P a yment Payment Type Che kA eceiipt 4 Received By Account ID �� D c7 ' 0( � — ✓ S/ - !O 0003775 Facility ID Program Record ID PIE Assigned to PWS ID FA0004113 PR0270321 2765 2424-VELOSO-CACAPIT WA0515747 Report#:7066.rpt n Date a a 12 Application Printed:10/25/2011 0 z(�(o lo�