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aquinCounty-EnvironmentalHealthDepart RECEIVED 600 E.Main Street-Stockton CA 95202-Phone: 209-46.�_2pr - ��1�4 va ' t_U Va LuV APPLICATION QQ ENVIRONMENTAL HEALTH V ONMENTAL HFALTH PERMIT TO OPERATE kN G p,L EMPLOYEE HOUSING OR LABOR CAMP 30 MiWvl�,nE RMIT/SERVICES sa�Gt,�l�?o_Pw �Z ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) N Annual Permit for Calendar Year ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID# 0019362 *Additional Employees State ID#: 39015751 EH ID#: 39000425 Please(Vote anti Corrections or Changes in F'acili/v/Operator Information directly on dlisf rtil. 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(honer: SAMBADO,LAWRENCE J&BEVERLY New Owner? ❑Yes [�fNo Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone#:(209)931-2568 Communit - ilities Provided by Cam Community Kitchen? ❑ Yes Da No Men: Number of Toilets VAM-LL_Y Number of Showers Number of Lavatories Women: Number of Toilets NQ LLS1:1\)G Number of Showers Number of Lavatories Ilousina Accommodations to be Utilized this Year: Occunancv Dates: Buildings Emplovecs Dormitories from�_/0(/`A=, to/3� /OZOio1 Crop W SF Dwellings from / / to_/ / Crop Apartments Owner Owned H RV Total Number of Days to be used this Calendar Year: 3 S 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 F.J Require a P1113LIC WATER SYSTEM Permit ❑Inactive 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. Fee Schedule Pemtanent Camp Annual Permit Fet $35.00+ Number of Employees 10 If a $12.00 each=$ ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ 'Transfer ofOwncrship $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees a $12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees a $24.00 cacti=$ Fee must be submitted with Application _ TOTAL FI?E DUES 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,Subehapter 3,Title 25 California Code of Regulations. Applicant Name LAWRENCE: �AMRA Title PR SSDENT El Partnership (Please PRINT or TYPE) Corporation Address a0T =N N a Phone Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Check/ ceipt# Received By Account ID --IV` 57_19 Y_ e?w— 0033238 7FAFacility ID Program Record ID P/E Assigned to PWS ID 0018722 PR0527631 2765 - OSO-CACAPIT WA0515744 �I 13 tl�r� Date z I Z yplication Printed:10/25/201 t Report#:7066.rp � 6 Ila#zz��S