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PAYMENT Joaquin County-Environmental Health Depar RECEIVED 1868 E.riazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 DEC 2 9 2021 SAN JOAQUIN COUNTY APPLICATION ENVIRONMENTAL ENVIRONMENTAL HEALTH HEALTH DEPARTMENT PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP �,,/ /� ❑New Camp E]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) IYI Annual Permit for Calendar Year C10 -1]Amended Permit: *Change of Operator *Change of Owner T� _ *Change of Operator Address *Change of Owner Address Permit ID#• 0019362 *Additional Employees } State ID#: 39-15751-EH Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000425 Site Name: S C RANCH 39-425 Location: 17421 E COMSTOCK 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 J&BEVERLY New Owner? ❑Yes No OwnerA.ddress: 8077 N TULLY RD, LINDEN CA 95236 Owner Phone#:(209)931-2568 Community Facilities Provided by Caron: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets An.. Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Emnlovices Dormitories from Qt/ to /3 / l a Crop SF Dwellings from _/ / to / / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive Im op rtant: 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. Fee Schedule Permanent Camp Annual Permit Fee $50.00+ Number of Employees 10 @$15.00 each=$ 5�• Ql ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application a Q0 TOTAL FEE DUE$ Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to 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,California Code of Regulations. Applicant Name LAW RED e E o AM BARD Title PR E r ��❑yPartnership (Please PRINT or TYPE) Corporation Address soyrr N. —CULLYIP LIND E Phone a,Qq_43(_asha Applicant Signature Date of Application I �L • a�—�,' Amount Paid Date of Payment Payment Type Check Receipt# Received By Account ID 0033238 • � '"I I �ff lX Facility ID Program Record ID P/E Assigned to PWS ID FA0018722 PR0527631 2765 3611 -GIRARDI WA0515744 Report# 7066 Application Printed:12/2/2021