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foaquin County-Environmental Health Depart <br /> 600 .Main Street-Stockton CA 95202-Phone: 209-4u.-j420 <br /> PA <br /> lb (i G APPLICATION <br /> Ok (�1 J ENVIRONMENTAL HEALTH JAN 13 <br /> 011 <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP SAH JOAQUIN <br /> H�gE�RONME'VT'1J Y <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit focpt�M <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. 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 FA M=LY Number of Showers Number of Lavatories <br /> Women: Number of Toilets H D usnu r-r Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> M/�1Ro-! ��BER p ORCHARD <br /> Dormitories ,r �� from to Crop <br /> SF Dwellings 2 M from _/ / to_/ / Crop <br /> Apartments <br /> Owner Owned RV 3 Total Number of Days to be used this Calendar Year: a 50 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: IYO N E <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> L�IJ 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 thi an return this application. <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fe( $35.00+ Number of Employees @$12.00 each=$ ( a 0• 6 <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 C216. ,t V <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,Ca'arnia Code of Regulations. <br /> Applicant Name L ALL)R E NC E t. A A BPI DO Title Pk EST-1)ENT El Partnership <br /> (Please PRINT or TYPE) Corporation <br /> Address CA 9 a Phone _q3f—Q5(oS <br /> Applicant Signature Date of Application 0 _Qoil <br /> Amount Paid Date of Payment Payment Type Checl(IReceipt# Received By Account ID <br /> C C y \ q �\ / �) b 11 I 0003775 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0004113 PR0270321 2765 2424-VELOSO-CACAPIT WA0515747 <br /> Report#:7066.rpt �hD 2 le 2G� Application Printed:11/2/2010 <br />