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� k <br /> Joaquin County-Environmental Health Depar A <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209468-3420 <br /> PAYMENT <br /> APPLICATION JAN _2 2013 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE ` JOAgUIN CO <br /> EMPLOYEE HOUSING OR LABOR CAMP EMVIROh'M- U <br /> UMTy <br /> HEAL7}t 1) LN A <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent(lousing Camps only) ❑Annual Permit for Calendar Yelil <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0019362 <br /> *Additional Employees State ID#: 39015751 <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? E] Yes �o <br /> Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone#:(209)931-2568 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes No <br /> Men: Number of Toilets F Number of Showers Number of Lavatories <br /> Women: Number of Toilets N Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this l car: U Occupancy Dates: <br /> Buildimus Employ <br /> Dormitories from Q/Q/_&Q{(`J_La/_$I /� Crop W R L'"W `S <br /> SF Dwellings 2 Q from _/ / to_/_/ Crop <br /> Apartments <br /> Owner Owned IH RV g g Total Number of Days to be used this Calendar Year: 31p s <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> AF— <br /> MH/RV Spaces N9k <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 <br /> Permanent Camp Annual Permit Fet $35.00+ Number of Employees @$12.00 each=$ 1 a0• 00 <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> L7 Transfer of Ownership $20.00=$� <br /> Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ 155.d0 <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 3,Title 25,California Code of Regulations. <br /> Applicant Name LAWRENCE 2AME36M Title � _SM nEN7— ❑Partnership <br /> (Please PRINT or TYPE) )O Corporation <br /> Address L7-/UD q Phone f >Ct'�I—atj(oQy <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 5177cS 0033238 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0018722 PR0527631 2765 242 - ep CACAPIT WA0515744 <br /> Oaks <br /> Report#:26F}.rot Application Printed:11/l/2012 <br />