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k S, oaquin County-Environmental Health Departr 600 E.Main Street-Stockton CA 95202-Phone: 2094b�-A20 PAYMENT APPLICATION RECEIVED ENVIRONMENTAL HEALTH PERMIT TO OPERATE JAN 13 2011 EMPLOYEE HOUSING OR LABOR CAMP SAN JOAQUI'N COUNTY ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for CalendliupXp� ❑Amended Permit: *Change of Operator *Change of Owner HEAL7H 0EPART,ENT *Change of Operator Address *Change of Owner Address Permit ID# 0019362 *Additional Employees State ID#• 39015751 Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000425 Site Name: S C RANCH 39-425 Location: 17421 E COMSTOCK 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 J&BEVERLY 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 t=AM=LY Number of Showers Number of Lavatories Women: Number of Toilets HO L 5 S'NG Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories from MARC-H to Or_Tn,a ER Crop SF Dwellings from / / to_/_/ Crop Apartments Owner Owned&RV p Total Number of Days to be used this Calendar Year: Owner Owned RR Cars —1)--- Total Days Occupied by 25 or more Employees: MH/RV Spaces Note TOTALS /�� Camps occupied by 25 or more Employees for 60 or more days in a year {-=J Require a PUBLIC WATER SYSTEM Permit ❑Inactive 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. Fee Schedule n Permanent Camp Annual Permit Fe( $35.00+ Number of Employees �_ @$12.00 each=$ ( Ot-C)• 00 ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ 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$ 1 55•Q(5 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 L.A W R ENC'E SAMBADO Title {P RES1:r)Pj\rr ❑Partnership (Please PRINT or TYPE) WCorporation Address rfrJ 1 M11 1 V PD. Lx7ArDEAJp45SOL Phone aiO4-431-25b0 Applicant Signature Date of Application 1- 1 Q-1 1 Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 0033238 Facility ID Program Record ID PIE (Assigned to PWS ID FA0018722 PRO527631 2765 2424-VELOSO-CACAPIT WA0515744 Report#:7066.rpt Application Printed:11/2/2010