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- vuu vvuyU I II vvUII L ) ". Ub I / F. 1 <br /> San joaquirl Coullty-Environmental Health Wpa_ .tent P4YMENr <br /> 1800 I;.Hazelton Avenue-Stockton CA 95205-Phone; 209-469-3420 RECF,I� <br /> APPLICATION SAN <br /> ENVIRON51ENTALIIEALT}j ENVAG)Ulli1 COU <br /> 1--t EMPLOYEEPERMIT TO OPERA BOR C HEALTf j t)V f A TMj_ <br /> U New Comp ❑Condilional Permit Elrlplllple fears(Permanent Housing Cpm onl• NT <br /> ❑Amonded Permit: *Change ofp 0 cralur *ChanQo of Owner y) FIAnnual Permit for Calendar Year_Z (C <br /> *Change of Operator Address *Change of Owner Address <br /> *Addluonal Employees Permit 1D p; 0019362 <br /> State II!h: 39-15751-EH <br /> Pleose Note orry Corrections or Changes in Faell/t3/opero(or Information directly on thtsjona 9H ID#: 39000425 <br /> rNarnE: $C RANCH 39-425Location: 17421 E COMSTOCK RD,LINDEN <br /> A SAMBADO&SON INC <br /> -------------- <br /> s: 8077 N TULLY RD,LINDEN CA 95236 <br /> 1 aclllly Phone 4;(209)931-2568 <br /> SAMBADO,L4WRENCE i 8 13EVERLY <br /> --------------- <br /> IYewOwnery <br /> 8077 N TULLY RD,LINDEN CA 95236 <br /> Communlly Raelllties Pro►•ided b an,n Owner Phone 9:(209)931.2568 <br /> !-t` _. Community Kitchen ❑ Yas No <br /> Men: Number of Toilet, F� Number of Showers <br /> Women: Number of Toilets Numbcr ol'Lavatorics <br /> Numbcr of 5howeis Number of Lavatories <br /> I3illlSlllLc�cc.nknl IIIions to b 7tlllzed till* <br /> Occupao v Date*• <br /> Iluildin� Emploveee <br /> Dorro ilories <br /> from d 11�1 la / _ P 4t-A/t.C1j s <br /> SF Dwellings _e from �.�/ � crop �. <br /> Apartments - —�/ tom/ / Crop <br /> Owner Owlte(MF!/kV <br /> Total Number of Da)s to be used this Calendar Year, e <br /> OH Owned <br /> I TOIa)D Oc <br /> cupied ccupied by 25 Or more Employees: <br /> MH RV Spaces <br /> Cars <br /> TOTALS <br /> 1 � Camps occupied by 25 or more Y'mplo}•ees for 60 or mart da)•s in a year <br /> Q Inactive Rettuire a J?(JALIC WATER SYSTEM Pcrmll <br /> Important: In order to proteetyour land use status,if camp Hill not be used this year but is intended for use in the future,Check this f3os and return this;application. <br /> Fee eduir. <br /> Penitanenl Camp Annual Permit Pet $35.00+ � � <br /> Number of>mplo}ccs —L1L @,$12.00 cach=$ O <br /> ❑ Otehard Camp Permit Fee Nuurbcr of 2mployecs <br /> ❑ 1YansfcrofOHnenhil) $95.00=$ <br /> ❑ Permanent Amendment Fee $2U.t1U+ Number ol-Addil i0oal Employees $20.00=$ <br /> $70.013+ <br /> ❑ I-ale Application Fee QQ $12.00 each=$ <br /> NumberoPEmployecs r <br /> FeemustbeSubtlll(tedtiw•ithApplication �` $24.00 each=$ <br /> TOTAL BEC AUE S S <br /> ltemll TOTAL FEE as CALCULATED ABOVE In the ENCLOSED Self-ndressed Envelop, <br /> NIAKE CHECKS PAVAALE to CHD <br /> Applicant a):reea to all necessary inspections Incident to Issuance of a PERNHT TO OPERATE. Applicant agrees that this projecl(camp)shall be operated <br /> and maintained In acctrl•dance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapler 1,Pari 1, Dirision Hentlb <br /> andSofe&Code and Chapter 1,Subchapler 3,Title 25,Caljaiala Code ofRegrl/rrllons. 13 of the Cnllfornln <br /> Applicant Name I CrN <br /> (Please PRINT or TYPE) Title <br /> U Partnership <br /> Address 80?7_ N. ^T(— LL DEA) O-A a sa Corporation <br /> Appllcoalit Signa P11ono ture aA (R31 a�Jt6 <br /> Date ofAppllcation r-7�I <br /> Amount Paid Pale of Pa Payment Y Payment Type ChocklRecelpt 9 Received By Account Ib <br /> �v�'qd.S 0033230 <br /> Facility ID Program Record ID PIE <br /> FA4018722 Assigned 10 PWS to <br /> I'RO527631 2765 2424-VELOSO <br /> WA0515744 <br /> Reoori Ak 7066 <br /> 4 nnn;t <br />