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Joaquin County- Environmental Ilealth Depar it 304 E Webe. .enue-Third Floor-Stockton CA 95202-Pho. 209-468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: 0005643 Please Note any Corrections or Changes in Facility/Operalor Irr/ormation directly on this 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#:(209)931-2568 Community Facilities Provided by Camp. ��C� ommunity Kitchen: Yes NLJ Men: Number of Toilets t"(&W I(w Number of Showers Number of Lavatories Women: Number of Toilets 1JM V4 L +yam Number of Showers Number of Lavatories _ Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees from IJV/"o qto 04 Crop _L-Y C"A Dormitories from_/_/_to_/_/_Crop SF Dwellings Apartments Total Number of Days to be used this Calendar Year—Z-5z) Owner Owned MH/RV Total Days Occupied by 25 or more Employees Owner Owned RR Cars Note: MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year TOTALS require a Public Water System Pe PAYMEfv..,. 0 RECEIVED ❑ Inactive DEC � � 2003 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 applica io SAN JOAQUI GO Fee Schedule "mvINUNML qE TAL ❑Permanent Camp Annual Permit Fee: $35.00+ Number of Employees 10 @ $12.00 each=$A�TU OF PAC T&NT ❑ Orchard Camp Permit Fee: $95.00=$ `J`� nn Transfer of Ownership: $20.00=$ ❑ Permit Amendment Fee: $20.00+ Number of Additional Employees r@ $12.00 each=$_ Late Application Fee: $70.00+ Number of Employees cGJ$24.00 each=$ Fee must be uQmitted with Application TOTAL FEE DUE: s 55 dC7 Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope MAKE CHECKS PAYABLE TO: PHS-EIID 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 flealth and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name (j( Ye4-2 CC- SG{,yy,r b,06;' Title �i ❑ Partnership (Please PRINT or TYPE) ❑Corporation Address '� ) �(-('y C4 LeAIA,� [) Z36 Phone(2o9) q3 i - 9, Applicant Signature Date of Application 1 Z C Amount Paid Date of Payment Payment Type ec eceipt# Received By Account ID 1+) n la— Facility 0003775 4( v� ID Program Record ID P/E Assigned to PWS ID 0004113 0270321 2755 I Q1522-VAN BUREN 0005643 Report#:7066.rot L VY" ' t / Application Printed. 11/19/2003