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Fete-22-05 02 : 54P P-08 San Joaquin County`Faylronmental Health Department PAYMENT 304 E Weber Avenue-Third Floor-Stockton CA 95?02-Phone: 209-468-3420 RECEIVED r_"b APPLICATION ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR.CAMp HEALTH DEPARTMENT ❑New Camp ❑Conditional Permit ❑ 'tultiple Years(Permanent Housing Camps only) ❑Annual Permit for, lender Year ❑Amended Permit: *Chance of Opt—wr •Cha,ige of Owner 'Change of Operator Address "Change of Owner Addrr>s 'Additional F'.mpinyers Pernitc In#: 0005643 Please Note any Corrections or Changan in Facility/Operator brfornrutrun directly on this Camp 11)#: 39000321 Site Name; A SAMBADO 8 SON 3a-321 Location: 14000 E EIGHT MILE RD, LINDEN Operator: A SAMSA00&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#:(209)931.2568 Community Facilities Provided by Camp: Cnnsmunity Kitchen'.' ❑ Yes ❑ No Men; Number of Tuilcis F� 9,t Number of Showers Nornbcr of Lavatoncs Women: Number of foilets 4Las 1 Numhcr of Shmvcm Number of Lavatories Housine Accommodations lu be Utilized this Yew Oceunancv Dates: Uuildines Employees IArnnitorics to Oe26k1G r Crop C>vf l�of SF Dwclliuy's irum ___—/ 1<'—�_..__�.. .. Craft T Apartments Owner Omied MI I/RV Total Numbtrr of Days to be used this Calendar Year: ��p )wner Owned RR Czars Tntal Days Occupied by 25 or rnore Employees: Vto yte MH/RV spaces L4= TOTALS Camps occupied by or more Employees for TI more days In a year Requiree a PUBLIC WATER SYSTI:M Permit ❑inactive jguortggt: In order to protect your land use status,if camp will Our be used this year but is intended for use in the future.Check this Box and return this application, Fee Schedule fb Permanent Camp Annual Permit Fe $35,00+ Number of Employees /O @ S 12.00 each-$ I. ❑ Omhard Camp Permit Fee $95.(N)=$ ❑ Transfer of Ownership S20.00-S ❑ Pertttarsent Amenditxnt Fee S20.00+ Number of Additional Employees L S 12.00 each=S ❑ Late Application Fez S70.00+ Numbs of Employees @$24.00 each=S Fee must be submitted with Application TOTAI.FF-t:DNE S 155. Remit TOTAL FEE&s CALCULATED ABOVE In the ENCLOSED Self-&dressed Envelope MAKE CHECKS PAYABLE to END .err Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this pmjeet(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 Sefety Code and Chapter I,Subchxpter 3,Title 26,CaNfomia Cade oflttaulaflons. r e S , Parmuship Applicant Name � t1.,.,y cL�iV�CG Cj t�-..,,,�j _ Title 'c(•e n'� � d (P'taeseARltvrorrype) ®Corponuoe Address o 7-7 "(^ � �; P>^ (f} Phone q3 j -3.SL� Applicant Signature Cw. d Date of Application Amount Paid Dato of Paynwnt Payment Type ChacW tolpt Y Racalvad e y Account Iq 53 Z3'OS Y�377 7 0003775 Facility ID Program Record ID PIE Assigned to PW8 ID FAD004113 PR0270321 2755 1522-VAN HL.IHE.N NIA Reoon x 70k15.rot J, (� l 3 6 Application Printed:10/2012004