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San Joaquin County-Environmental Health Department {��/n/1 E!c t T <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-34 RECEIVED <br /> I <br /> APPLICATION JAN 0 5 2021 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP SAN JOAQUIN COUNTY <br /> ,,I'^�r-E�N.VV II RO NpMAEpN�ThAA AL <br /> ❑ E] A' I <br /> New Camp Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) �rgLl�erWK)allddaM'e>r�' a <br /> E]AmendedPermit: -Change of Operator "Change of Owner l <br /> *Change of Operator Address "Change of Owner Address Permit ID#• 0005643 <br /> "Additional Employees <br /> State ID#: 39-0321-EH <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 XN, <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 % 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: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from�/_0 -�to-a/X/_JD_L Crop <br /> SF Dwellings from_/ / to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV j Total Number of Days to be used this Calendar Year: �2 <br /> Owner Owned RR Cars !•�— Total Days Occupied by 25 or more Employees: /V Oki <br /> MH/RV Spaces Note <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 O <br /> Permanent Camp Annual Permit Fee $50.00+ Number of Employees 115 @$I5.00 each=$ a a 5, D <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUES ' 1 5� O O <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,California Code of Regulations. <br /> Applicant Name L. A W R E Ill('E IA M BADn Title P R S_ /OWN ER El Partnership <br /> PRINT or TYPE) Corporation <br /> Address Lz NDE Phone `a109_ 931 — a9168 <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type ChecktReceipt# Received Account ID 1 <br /> -4 0003775 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0004113 PR0270321 2765 001 - 1 WA0515747 <br /> Report# 7066 Application Printed:1 111 9/2 02 0 <br />