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S-- Toaquin County-Environmental Health Depar- t PAYMENT <br /> 600 ain Street-Stockton CA 95202-Phone: 209- J420 R ECEiVE❑ <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 0005643 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this Camp ID#: 39000321 <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 New Owner? ❑Yes ❑ No <br /> Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone#:(209)931-2568 <br /> Communitv Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets j��/((,' Number of Showers Number of Lavatories <br /> Women: Number of Toilets /y( f��A Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from to_Joe /L/r Crop O�CLi.4.� <br /> SF Dwellings 2 from _/_/ to / / Crop <br /> Apartments <br /> Owner Owned MH/RV I J Total Number of Days to be used this Calendar Year: '2S0 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: IY,91/to <br /> MH/RV Spaces <br /> 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 uses 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 Fe( $35.00+ Number of Employees if) @$12.00 each <br /> ] Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE S <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,California Code of Regulations. <br /> Applicant Name I—AW1047 , S#NhQd o Title r10�Xi0S-1 ,V 7 ❑Partnership <br /> (Please PRINT or TYPE) -�+ OCorporation <br /> d ! <br /> Address 77 "te L/.//t//0!9/V, 60 It 5-v2 3 Phone ?3l• i2 S74 e <br /> Applicant Signature Date of Application / 3Dlpa- <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> S < :Z 3 co) rG S� fn 1 1p iv (�;r- 0003775 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0004113 PR0270321 2 5 1421 -RIVERA N/A <br /> Uggeo <br /> ReDart 9 7066 rot D ; 1 �ZO 1 vU', Application Printed:10/30/2008 <br />