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Feb-22-05 02 : 54P P_08 San.Joaquin County-Fnvlronmental Health Department PAYMEN 1 304 E Weber Avenue-Third Floor•Stockton CA 95?02-Phone: 209-468-3420 RECEIVED APPLICATION ENVIRONMENTAL HEALTH SAN JOAQUIN COON(Y' PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR CA&►_' HEALTH DEPARTMENT ❑New Camp ❑Conditional Permit ❑ Multiple Years 1Permanent Housing Camps only) ❑Annual Pennit for Calendar Year �� w ❑Amended 1•rnnit: •Change nt('gxr�tur *Change of Owner *Change of Operator Address "Change of 0-ncr Addrrss *Additional F'.tnprnyer% Permit IT)#: 0005643 Please Note any Corrections or Changes in Facility70peralor Inlbrnruttun directly on this Camp ID#: 39000321 Site Marne: A SAMBADO&SON 30-321 Location; 14000 E EIGHT MILE RD, LINDEN Operator: A SAMEIADO&SON INC Mailing Address: 8077 N TULLY RD,LINDEN CA 95236 Facility Phone#:(209)931.2568 Lc2al Owner: SAMBADO,IAWRENCE Nc-Owner? ❑Yes [1 No Owner'Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone#:(209)931.2568 Community Facilities Provided try Camp: Community Kitchen" ❑ Yes ❑ No Men: Number of Tuilcls �61_.Skli Number or Showers N,t:nher of I avatoncs Women: Numberul toilets �rR 1 NumhcrofShenrcrs Number ofL:watorics Housing.Accummudaliuns to be 061izcd this Yeur= Occupancv Dates: Uuildines Employees Dorm:torics f!(olt _. - to Oet6LIk_ Clip CjV-CAV ere SI;f),cOlings froth ...._'_ to--� _/ Ur,ip Apartmen Is Owner OWot:d M I I t RV Total Number of Days to be used this Calendar Year: 'p )weer Owned RR Cars Tntal Days Occupied by 25 or morn Employees: Vlo Lip, MH I RV Spaces am TOTALS Camps occupied by 25 or more Employees for 6(1 or more days In a year Require a PUBLIC WATFR SYSTEM Permit ❑Inactive jfuppr(gl]l: In order to protect your land use status,if camp will nut he hied this year but is intended for use in the future,Check this Box and return this application, Fee Schedule Permanent Camp Annual Permit Fe S35.00+ Number of Employees (?S 12.00 each-S J ❑ Ol- hard Camp Permit Fee $95.(N)=$ ❑ Transfer of Ownership S20,00-S ❑ Permanent Amendimnt Fee $20.00+ Number of Additional Employees L$12-00 each=$ ❑ Late Application Fee S70.00+ Number of Employers a,S24.00 each=$ Fee must be submitted with Application TOTAL FF.£DUE$ I$S . 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 PE&MIT TO OPERATE. Applicant agrees that this pn>jeet(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Divisbin 13 of the California Health and Safery Code and Chapter 1,Subchapter 3,Title 257 California Code ofltegulallons. Applicant Name L- IY �,�) r�r.cG S c r� Title rr G s ;c( E'rt� 0 Partnership (Pleese PRINT or TYPE) L9 C.Orpmtlon Address 07"7 r � ; p,^ ��} Phone Gj31 —15-Lg' Applicant Signature Date of Applleation Amount Paid Date of Paynwnt Payment Type ChacklRecalpt 0 Recelvad E y Account 10 S V 3'OS 4(�3 7 j G003775 Facility ID Program Record ID P1E Assigned to PWS In FA01D041 13 PR0270321 2755 15?2-VAN HL.IREN NIA Rcuurt x 7066 rot Application Printed:10/29/2004