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• Toaquin Cou -Environmental Health Depart t PAYMENT <br /> 600. .ain Street-S ckton CA 95202-Phone: 209-• 3420 RFr`c:'\/Fn <br /> NOV 2 0 2007 <br /> APPLICATION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH ENVIRONMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <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 I 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 /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets J1.1arNumber of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Dormitories <br /> Buildings Employees from /1 to 00elx <br /> 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: p&1 <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 Permanent Camp Annual Permit Fe( $35.00+ Number of Employees IP @$12.00 each=$ <br /> ❑ Orchard Camp Permit Fee $95.00=$ <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$ <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 liform;* ;C76de Regulations.Applicant Name e�f�� �Jf Title ��(Q/f T [:1 Partnership <br /> (Please PRINT or TYPE) �J Corporation <br /> Address Phone s6 <br /> Applicant Signature Date of Application <br /> E- <br /> Facilityount Paid Date of Payment Payment Type Check4e-ceipt# Received By Account ID <br /> 0003775 <br /> ID Program Record ID P/E Assigned to PWS ID <br /> FA0004113 PR0270321 2755 2089-SOOD N/A <br /> Report#:7066.rot Application Printed:10/18/2007 <br />