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PAYMENT San Joaquin County-Environmental Health Department RECEIVED 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 AN APPLICATION SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ENVIRONMENTAL PERMIT TO OPERATE HEALTH DEPARTMENT EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) M Annual Permit for Calendar Year��, l ❑Amended Permit: "Change of Operator -Change of(Tuner I� -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 Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone#:(209)931-2568 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number o£Toilets Number of Showers Number of Lavatories Women: Number of Toilets CBA sly, Number of Showers Number of Lavatories Ci_ Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories from O/JOA/AlL to _ 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 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 Permanent Camp Annual Permit Fee $50.00+ Number of Employees In @$15.00 each=S 1150.0c) ❑ 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 TOTAL FEE DUE$ a 001 00 Remit TOTAL FEE as CALCULATED ABON F.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 L iQ WR ENC E 2AMBA DC9 Title ES. 10IONE p Partnership (Please PRINT or TYPE) ` f�pp`(Corporation AddressZ:Rto 01 Phone dnq_Q 3 I_OZ6:8 Applicant Signature OF Date of Application a-�� Amount Paid Date of Payment Payment Type hec eceipt# Received By Account ID 0033238 Fwacflity ID Program Record ID PIE Assigned to PWS ID FA0018722 PR0527631 2765 WA0515744 Report#:7066 Application Printed.11/19/2020