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loaquin County-Environmental Health Depar t 304 E Weber venue-Third Floor-Stockton CA 95202-Phol. 209-468-3420 APPLICATION iA111 U ENVIRONMENTAL HEALTH SAN jC) l_JQ PERMIT TO OPERATE ENV1 FI UhV COUNTY EMPLOYEE HOUSING OR LABOR CAMP IRON ❑New Camp ❑Conditional Permit E] Multiple Years(Permanent Housing Camps only) E]Annual Permit for Ca end e�p ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: 0005143 Please Note any Corrections or Changes in Facility/Operator Information directly on this I Camp 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 New Owner? ❑Yes ❑ No Owner Address: 8077 N TULLY RD, LINDEN CA 95236 Owner Phone 0#:(209)931-2568 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No -- Men: Number of Toilets AWIn-,Aj Number of Showers Number of Lavatories Women: Number of Toilets "�'—"--� Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occunancv Dates: Buildines Emvlovees ,.L Dormitories from �I4�-�h to m LP7� P.�Crop Q/QClteYt SF Dwellings from _/_/ to_/ / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 'S"U Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive 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. Fee Schedule Permanent Camp Annual Permit Fe $35.00+ Number of Employees �_ @$12.00 each=$ /02 ❑ Orchard Camp Permit Fee $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees (^a,$24.00 each=S Fee must be submitted with Application TOTAL FEE DUE$ 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 1, Part 1,Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant\ame MLL/,P1oW p .S.�mh&4& Title /JT ❑ Partnership (Please PRINT or TYPE) ,//�� Corporation Address 077 �(/, T ,020 &i✓,0f1/ (../1' �..�.5�� Phone �� 4"3/—e7slo Applicant Signature — _ Date of Application t _ _�_s G S - d U \ -- /-- 0003775 — Facility ID Program Record ID P/E Assigned to (3 PAIS ID FA0004113 PR0270321 2755 1522-VAN BUREN N/A Reoort#:7066.rpt V,VV ' 14 —7� Application Printed:11/17/2005