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1 <br /> BAN JOAQUIN COUNTY • PUBLIC HEALTH St-vICES <br /> ENVIRONMENTAL HEALTH DivisION <br /> 304 E WEBER AVENUE • THIRD FLOOR • STOCKTON CA 95202 • Phone: 209/468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> New Camp ❑Conditional Permit. ❑Annual Permit For Calendar Year <br /> ❑Amended Permit LJ Multiple Years(Permanent Housing Camps oa/r) ate Approved <br /> • Change of Operator -Change of Owner 0.tn Melled: <br /> • Change of Operator Address • Change of0wner Address p�rmlt y pp564; <br /> • Additional Employees amp ill#_39000321 <br /> Please Note any Corrections or Cleat es in Pac111 12 eraturr0[vner lu lrntallon(Iirect!x on this form. <br /> Site Name: SAMBADO,A&SON 39-321 Location: 1400 E EIGI-IT MILE RD <br /> Operator: SAMBADO,A&SON INC <br /> Mailing Address: 8077 N TULLY RD,LINDEN CA 95236 Facility Phone#: 209-931-2568 <br /> Legal Owner: SAMBADO,LAWRENC:E New Owner El Yes IL�No� <br /> Owner Address: M77 N'f ULLY RD,LINDEN CA 95236 Owner Phone#: 209-931-2568 <br /> Community Facilities Provided by Camp: , (t ommunity Kitchen: E)Yes ❑No <br /> Men: Number of Toilets i}1►i 1 ( Number of Showers Numbcr of Lavatories <br /> Women: Number of Toilets f4Q 144 f 11 Nnrnber of Showprs Ninnher of Lavaiarles <br /> Ilousln p Accom inxiatlunn to Ix-11lII e _11iln_Yrar: <br /> Buildin Employee Bundi�t tluulurees <br /> Dormitories: Owner Owned MH/RV __— <br /> SF Dwellings Owner Owned RR Cars <br /> Apartments MH/RV Spaces _ <br /> TOTAL of ROW COLLTitm <br /> Occupancy Dat rs: <br /> from to Crop � Total Numbcr orDays to he used this Calendar Year <br /> / / Total Days Occupied by 2.1'or more Employees <br /> from / / to Crop__ Note: Canyzc ornq.i(,d by 25 or more emplo)ves for 60 ormore r )s a year <br /> require a PuhNr INaler.Wm PerntlL <br /> FJ Inactive In order to protect your land use status,if camp will not be used this year but is intended for use in lhe,klure Check this Box and return <br /> I his appllcadon. <br /> Fee Schedule / 1� <br /> i permanent Camp Annual Permit$35.00+Number of Employees _ I O $12.00 Pitch S$ ��� I 4� <br /> �P,�avt --- <br /> `�� '���� ❑ Orchard Camp Permlt Fee=$95.00=S _ <br /> �j{�(�(� ❑ Transfer ofOwnership=$20.00-S <br /> FE13 ,� 7 F�Y`9nult Amendment=$20.00 t'Number of Additional Employees — (iji $12.00 each=S <br /> SAN JOACaUIN CUUNT� Date Application Fee$70.00+Nnmber of Employees__ (a,$24.00 each=$ <br /> PUBLIC HEALTH SERVICES <br /> i_NVII�ONMEN7AL HEALTH DIVISION Fee must be submitted with Application TOTAL FEE DUE: <br /> REr,TT TO'I'AL FEE AS CALC11LA"ITI)ABOVE IN THE ENCf.O.SFD sett addreSSed ENVELOPE. AfAIiF.C11FCh%SPAIi1RLF Tn: PIPS/Ella) <br /> r� <br /> Applicant agrees to all necessary Inspections incident to issuance of.a PERMIT 1'o OPERATE. Applicant agrees that this project(camp)shall <br /> be operated and maintained In accordance with the applicable provisions Of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the <br /> IIta11h and Saftty Code and Chapter 1,Subchapt/er Titll�e��2,,,�5,California Code ofRegukdons. <br /> Applicant Name r Q G� !G.ilia T-'1�_ Title �"�► 0 Partnership Uorporation <br /> Plraiv PF l T or 7YP • ' 1 <br /> ( At ess _ �71�r. + — ,MLI��. �t_sidOne. _I�g31-�5� <br /> Applicant Signature Date of Application <br /> Program Rec d Ill# 270321 Facility ID# 004113 Account ID# 0003775__� <br /> N_moL nt Paid Date of Payment Payment Type ipt N 7 ed Recely By <br /> �7►21� 3-751Q_ -- - <br /> Employee 0: Acct#: Fac ID: PR#: PWS ID#: P/E: <br />