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San Joaquin County-Environmental Health Department <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year C r'o <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0005643 <br /> *Additional Employees <br /> State ID#: 39-0321-EH <br /> EH ID#: 39000321 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: A SAMBADO&SON 39-321 Location: 14000 E EIGHT MILE 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? ❑Yes No <br /> Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone#:(209)931-26bb <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets 8061 Number of Showers Number of Lavatories <br /> Women: Number ofToilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees ^ n 1 <br /> Dormitories from �/Q�/ aA to / f��{' Crop U'f1�L,.•�d11J•�d•`�LL1 <br /> SF Dwellings rL from _/ / to_/ / Crop <br /> Apartments Lo__ <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3 lD 5 <br /> Owner Owned RR Cars Total Days Occupied by 25 or m N a N E <br /> MH/RV Spaces Note E� <br /> TOTALS ® Camps occupied by 25 orIM60 or more days in a year <br /> W <br /> Require a PUB A E TEM Permit <br /> Inactive' <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMEN�i <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 futuft�CSfi aEdttb 161and return this application. <br /> Fee Schedule <br /> Permanent Camp Annual Permit Fee $50.00+ Number of Employees @$17.00 each=$ a K� .Q 0 <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $100.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ 3o-F5. no <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 ',alifornia Code of Regulations. <br /> Applicant Name L A(A9R;z_NC F a A MBAD D Title ❑Partnership <br /> (Please PRINT or TYPE) <br /> Corporation <br /> Address 11 ILLY 0, L nU DM CR Q 6 Phone 011 q-Q-A I-Orlsa <br /> Applicant Signature Date of Application a_ t-a3 <br /> Amount Paid ate of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0003775 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0004113 PR0270321 2765 0039-GOODERHAM WA0515747 <br /> Report#.7066 Application Printed:11/1/2023 <br />