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F jaquin County-Environmental Health Departi. <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 PAYMENT <br /> ngCr=WEn <br /> APPLICATION OCT 31 20% <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE SMJOAQUIN COUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTAL <br /> HEALTH D"M E <br /> ' ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) XAnnual Permit for Calendar Year <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID# 0019362 <br /> *Additional Employees <br /> State ID#: 39-15751-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000425 <br /> Site Name: S C RANCH 39-425 Location: 17421 E COMSTOCK RD, LINDEN <br /> Operator: A SAMBADO&SON INC <br /> Mailing Address: 8077 N TULLY RD, LINDEN CA 95236 Facility Phone#:(209)931-2568 <br /> Legal Owner: SAMBADO,LAWRENCE J&BEVERLY New Owner? ❑Yes XNo <br /> Oryacr Address: 80�7 N TULLY RD, LINDEN CA 95236 Owner Phone#:(209)931-25e8 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ® No <br /> Men: Number of Toilets a Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> B it in Em IR ovees <br /> Dormitories from I C I/Tl—to Loa-/3t 17 Crop <br /> SF Dwellings -y Z from /_/ to / / Crop <br /> Apartments <br /> Owner Ownel MH RV ; Total Number of Days to be used this Calendar Year: 6 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> 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 application. <br /> Fee Schedule `s5' 0 <br /> Permanent Camp Annual Permit Fet $3&<+ Number of Employees @$12-9ffeach=$ ( 5o.on <br /> J <br /> ❑ Orchard Camp Permit Fee 'rs ` Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees a $12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ 1 CI5,DO <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1, Part 1, Division 13 of the California Health <br /> and Safety Code and Chapter 1,Subchapter 31 Title 25 California Code of Regulations. <br /> Applicant Name L A wR e me E' S A IM BADO Title F)g;:'S-c C)E O LO N ❑ Partnership <br /> (Please PRINT or TYPE) 1]4 Corporation <br /> Address T (. R /� Cp Phone <br /> Applicant Signature Date of Application �QQ'7- <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0033238 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> WA05157 44FA001 PR0527631 2765 8987-SANGALANG L <br /> Report#:7066 Application Printed:10/13/2016 <br />