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n Joaquin Count)-Environmental Health Del tent , AyMeN I. 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 !�F(�EIVF D APPLICATION 007 ENVIRONMENTAL HEALTH SAN jOAQUIt� PERMIT TO OPERATE HEALTtJ EN RONMENrAINTY L EMPLOYEE HOUSING OR LABOR CAMP ALTH DEPARTMENT ❑New Camp E]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year ❑Amended Permit: *Change of Operator •Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: 1111143::::] Please Note any Corrections or Changes in Facility/Operator Information directly on thr: Camp ID#: 39000321 Site Name: A SAMBADO&SON 39-321 Location: 14000 E EIGHT MILE RD,LINDEN Operator: A SAMBADO&SON INC Mailing Address: 8077 N TULLY RD,LINDEN CA 95236 Facility Phone#:(209)931-2568 Legal Owner: SAMBADO,LAWRENCE New Owner? ❑Yes ❑ No Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone#:(209)931-2568 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets �h7`r` Number of Showers Number of Lavatories Women: Number of Toilets 1)14ew Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees _�y� Dormitories from -//ur!}'eGh to 6)164001 le f' Crop Q��j( / SF Dwellings from _/ / to_/ / Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: e MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive Im portan t: 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. Fee Schedule Permanent Camp Annual Permit Fee $35.00+ Number ofEmployees @$12.00 each=$ /�d - ❑ Orchard Camp Permit Fee $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ Fee must be submitted with Application _ TOTAL FEE DUE$ Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1, Part 1, Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. Applicant Name Title (Please PRINT or TYPE) 4Wi>7 Partnership ❑ Corporation Address 907 Phone Jkfl -�,sG9 Applicant Signature Ae445��/ Date of Application Amount Paid Date of Payment Payment Type CheQ �ck ✓leipt# Received By Account ID S S, w \ 2-2-� 6 � ✓ 'A0 q l ('�) � &— 0003775 Facility ID Program Record ID PIE Assigned to PWS ID FA0004113 PR0270321 2755 1522-VAN BUREN N/A Report#:7066.rot 1 �-a' Application Printed:10/23/2006