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San Joaquin CountyPA','I��I\1 1- <br /> 600 E.Main Street epartment <br /> -Sock oo tCA 95202-Phonealth : 09468 3420 <br /> RECEIVED <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> ❑New Camp []Conditional Permit <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT <br /> ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <br /> []Amended Permit: *Change of Operator } <br /> "Change of Operator Address Change of Owner <br /> *Change of Owner Address <br /> *Additional Employees <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this �C=pPermit ID ID#:• 0005643 39000321 <br /> Site Name: A SAMBADO&SON 39-321 <br /> Location: 14000 E EIGHT MILE RA' LINDEN <br /> Operator: A SAMBADO&SON INC <br /> Mailing Address: 8077 N TULLY RD,LINDEN CA 95236 <br /> g SAMBADO,LAWRENCE J&BEVERLY Facility Phone#:(209)931-2568 <br /> Legal Owner: <br /> Owner Address: 8077 N TULLY RD,LINDEN CA 95236 New Owner? ❑ <br /> Community Facilities Provided by Cam Owner Phone#:(209)931-2568 <br /> M Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets <br /> Women: Number of Toilets �� Number of Showers Number of Lavatories <br /> Number of Showers <br /> Housing Accommodations to be Utilize Number of Lavatories <br /> d this V <br /> UCCUDBmCV Dates• <br /> Buildig Employees <br /> Dormitories <br /> SF Dwellings from 1�—/_-�JILtb <br /> from <br /> Apartments —/ f0_// Crop <br /> Owner Owned MH/RV <br /> Owner Owned RR Cars Total Number of Days to be used this Calendar Year: <br /> MH/RV Spaces Total Days Occupied by 25 or more Employees: <br /> /I e <br /> TOTALS Note <br /> Camps occupied by 25 or more Employees for 60 or more days in a year <br /> ❑Inactive Require a PUBLIC WATER SYSTEM Permit <br /> Important: In order to protect your land use status,ifcamp will not be used this year but is intended for use in the future,Check this Box and return this application. <br /> Fee S�use <br /> Permanent Camp Annual Permit Fe( $35.00+ <br /> Number❑ ofEmployees --Z sL_ @$12.00 each Orchard Camp Permit Fee <br /> ❑ Number of Employees Transfer of Ownership $95.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees $20.00=$ <br /> ❑ Late Application Fee $70.00+ @$12.00 each=$ <br /> Number of Employees <br /> Fee must be submitted with Application " $24.00 each=$ <br /> TOTAL <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adress dEnvelope <br /> E DUE$ <br /> MAKE CHECKS PAYABLE to EHD <br /> pplicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> id maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter <br /> rd Safety Code and Chapter 1,Subchapter 3,Title 25,Cal/fornia Code ofRegu/ations. 1, Part I, Division 13 of the California Health <br /> rplicant Name <br /> 'ease PRINT or TYPE) ���//��ISGQ Title �riP� 1p`) <br /> 7` El Partnership <br /> dress or� orporation <br /> plicant Signature <br /> S.Z 3 Phone .0I, c 5`(0 <br /> Date of Application / 12Ul <br /> Amount Paid Date of Payment <br /> Payment Type ChecW RAceiUgt# Received By Account ID <br /> \ ✓ 5 y 3 3 1 0003775 <br /> Facility ID Program Record ID <br /> PIE Assigned to FA0004113 PR0270321 PWS ID <br /> 2765 1421 - <br /> - WA0515747 <br /> ,ri#:7066.ro1 <br /> �n0)9L-/g7//2 <br />