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c Joaquin County-Environmental Health Depart It <br /> 600 ain Street-Stockton CA 95202-Phone: 209- ,420 pgYMENT <br /> REcF-1vED <br /> APPLICATION D E c 3 1 zoo s <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE SAN JOAQUIN COUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTAL <br /> 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#: 0019362 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this JCamp ID#: 39000425 <br /> Site Name: S C RANCH 39-425 Location: 7'�Z Coon }DcK R4. <br /> Operator: A.SAMBADO&SON INC L%h4,!h C4 . <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 (,L S nCj Number of Showers Number of Lavatories <br /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees A /_ �,,Ae��/ <br /> Dormitories from eAn�/i to&e 4 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: <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,ifcamp will not be used this year but is intended for use in the future,Check this Box and return this application. <br /> Fee Schedule 0/ Oo <br /> Permanent Camp Annual Permit Fet $35.00+ Number of Employees �_ (a?$12.00 each=$ /� ' <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$ <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 A"Iewp ,-�/ *wy Title Pwios//,�PNT ❑Partnership <br /> (Please PRINT or TYPE) ./ p Corporation <br /> Address 8a 77 A • 7 a w,,,wx L�i4 5-.�3 Phone 7.31.25'lO Op <br /> Applicant Signature Date of Application l2/67Q/1PY <br /> Amount Paid Date of Payment Payment Type Check/Rtmwiptlk Received By Account ID <br /> 5 - �21 3 g l <br /> ( ' o -5 l b `( k NZI- 0033238 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0018722 PR0527631 27 5 1421 - RIVERA N/A <br /> Report#:7066.rot Date ) �� Application Printed:10/30/2008 <br />