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r Sar quip County-Environmental Health Departmr 304 E Weber A -je-Third Floor-Stockton CA 95202-Phone: -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/Operator In/ormalion rlrrectly on this Camp ID#: 39000321 Site Name: A SAMBADO&SON 39-321 Location: 14000 E EIGHT MILE RD,UNDEN 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 it:(209)931-2568 Community Facilities Provided by Camp: Cp nmunity Kitchen: YesN Men: Number of Toilets "� Number of Showers Number of lavatories Women: Number of Toilets LI Number of Showers Number of Lavatories _ Housine Accommodations to be Utilized th�iss Year: Occu nanc•Dates: Buildings Employees from In Crop Dormitories from_/_/_to_/_/_Crop _ SF Dwellings Apartments Total Number of Days to be used this Calendar Year-;.S 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 Permit. ❑ Inactive Important: In order to protect your land use status,ifcamp will not be used this year but is intended for use in the future,Check this Box and return this application. Fee Schedule S Permanent Camp Annual Permit Fee: $35.00+ Number of Employees 0 C $12.00 each=$ ,,5V• Q ❑ Orchard Camp Permit Fee: $95.00=$ �n Transfer of Ownership: $20.00=$ Permit Amendment Fee: $20.00+ Number of Agional Employees � $12.00 each=$_ ❑ Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ Fee must be ubmitted with Application / C n�f► TOTAL,FEE DUE: Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope MAKE,CHECKS PAYABLE TO: PHS-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,Califo,r[nia�Code �of Regulations. Alicant Name Pp /� t M GC V WU Title �. Partnership �Ji�r E](Please PRINT or TYPE) $k Corporation Address Pho Applicant Signature Date of Application Amount Paid Date of Payment Payment Type ec Recelpt# Received By Account ID 1'5 . eb I b 03 tI-11 If P 0003775 Facility ID Program Record ID PIE Assigned to PWS ID 0004113 0270321 2755 1522-VAN BUREN 0005643 Report#:7066.rot �� -2-c)- Application Printed:11/20/2002