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' San Joaquin County-Environmental Health Department <br /> 1868 E Hazelton Ave-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 2026 <br /> ❑ Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> State ID#: <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: S C RANCH 39-425 Location: 17421 E COMSTOCK RD LINDEN <br /> Operator: SC RANCH 39425 Email: <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 IVINO <br /> Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone#: (209)931-2568 Email: <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets W�/y/l Number of Showers Number of Lavatories <br /> Women: Number of Toilets M Number of Showers Number of Lavatories <br /> OF V <br /> Housin¢Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildines Employees <br /> Dormitories from ell 01116 to / /z 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 /> MH/RV Spaces Note <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 �t <br /> Permanent Camp Annual Permit Fee $54.00+ Number of Employees @$17.00 each=$ <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$17.00 each=$ <br /> ❑ Late Application Fee $108.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed 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 and <br /> Safety Code and Chapter 1, ubchapter 3,Title 25 alifornia( e of ftuladons. <br /> Applicant Name (,�/ er Title jlj� ❑Partn�tship <br /> (PleasePRINTor E) f� s/� /��C/Ojorationn <br /> Address l J // n O Or'l / Phone VG°% <br /> Applicant Signature Date Hf Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0018722 PRO527631 765 aron Gooderham <br /> Report#:7067.rpt RECEIVED <br /> )EC 2 2 2025 <br /> :,AN JOAOUIN COUN I Y <br /> ENVIRONMENTAL <br /> HEALTH OEPARTMLNI <br />