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San Joaquin County-Environmental Health Department <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 <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.&D,'4 <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0011914 <br /> *Additional Employees State ID#: 39-15729-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000370 <br /> Site Name: A SAMBADO&SON 39-370/WTR SYS Location: 15294 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)931-2568 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets rvnlo. . Number of Showers Number of Lavatories <br /> Women: Number of ToiletsHaua�WF <br /> Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this 1'car: Occupancv Dates: <br /> Buildings Emplovees <br /> Dormitories from 01 / 01/_aA to i Oa./cal/ 07,14'_ Crop <br /> SF Dwellings from _/ / to_/ / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> ME/RV Spaces to <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 /> Im porta nt: 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 Fee $50.00+ PAYMEWber of Employees 1� @$17.00 each=$ <br /> ❑ Transfer of Ownership RECEIVED $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of� t�Employees @$17.00 each=$ <br /> ❑ Late Application Fee $100.00+ DEC of Employees @$34.00 each=$ <br /> Fee must b&,AV&a1jl0e&with Application <br /> ENVIRONMENTAL TOTAL FEE DUE$ Q�V Dom/ <br /> HEALTH DEPARTMENT <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 31 Title 25 California Code of Regulations. <br /> Applicant Name LAwp,>GacE 2�MBAG6 Title ��� �O�NEF�- Partnership <br /> (Please PRINT or TYPE) �orpotation <br /> Address iN T Phone OCIJ'1� ABB- a <br /> Applicant Signature 1)ate of Application <br /> Amount Paid Date of ayment Payment Type Check/Rec ipt# Received By Account ID <br /> LGA,-__ / c'�� 0023136 <br /> Facility ID 6 Program Record ID P/E l '' Assigned to PWS ID <br /> FA0013764 PR0518217 2765 0039-GOODERHAM WA0515716 <br /> � 0 ilk <br /> Report#:7066 Application Printed:11/1/2023 <br />