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Joaquin County-Environmental Health Depart R� %L•,, V/�D <br /> 600 t.Main Street-Stockton CA 95202-Phone: 2094bz;-34.2k � l <br /> OA`(M�IGO - - <br /> �VE t TO. I L-v V LUIL <br /> APPLICATION QQ <br /> ENVIRONMENTALIIEALTII �va ONMENT,41_HEgL <br /> EMPLOYEE HOUSING OR LABOR CAMP JOPpPERMIT TO OPERATE NM ��,EIRMIT/SERVICES TM <br /> SPN� N\Ft D� <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent(lousing Camps only) N�Annual Permit for Calendar Vear <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0019362 <br /> *Additional Employees <br /> State ID#: 39015751 <br /> EH ID#: 39000425 <br /> Please Note an_v 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: A SAMBADO&SON INC <br /> Mailing Address: 8077 N TULLY RD,LINDEN CA 95236 Facility Phone#:(209)931-2568 <br /> Legal(honer: SAMBADO,LAWRENCE J&BEVERLY 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 FAMELLY Number of Showers Number of Lavatories <br /> Women: Number of Toilets Nt7 u-S=t'j& Number of Showers Number of Lavatories <br /> llousine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from a l_/0 l/-a�o QL/3l /OQOIQ.Crop <br /> SF Dwellin__s 2 fnnn /_/ to_/_/ Crop <br /> Apartments <br /> Owner Owned H 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 ALS 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 <br /> Permanent Camp Annual Permit Fer $35.00+ Number of Employees O a $12.00 each=$ oZ <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 @t $12.00 each=$ <br /> ❑ I atc Application Fee $70.00+ Number of Employees L$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUES <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 LAWR,ENG[ CAMRA Title P'RRF=)EN—r ❑ Partnership <br /> (Please PRINT or TYPE) Corporation <br /> Address S�� L=N N Phone106 <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/ ceipt# Received By Account ID <br /> -0 15S'• � L7 ---j S/1 L ✓ 57-1 9 P I ;?z 0033238 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0018722 PR0527631 2765 - OSO-CACAPIT WA0515744 <br /> Report#:7066.rct Date 2 1 z plication Printed:10/25/2011 <br />