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San Joaquin County-Environmental Health Department <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 <br /> SAN���QUIN"OUNTI APPLICATION <br /> ENVIRONMEN SENT ENVIRONMENTAL HEALTH <br /> N pE'S"' PERMIT TO OPERATE <br /> HEpLT EMPLOYEE HOUSING OR LABOR CAMP ENVIR�I^li i tl:j y •�t:i_�i��`� <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for ry�{e�¢aR!Xe 1 nt•, <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees Permit ID#• 000 00 <br /> 'ease Mole any Corrections or Changes in Facility/Operator Information directly on this <br /> Camp ID#: 3900"54 <br /> Site Name: LadtLn ©rohards 39-� Location:�)�QQ ��rA�ttl� 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: O�Gj 101 V► <br /> dot , � 1�n+ty�`'C New Owner? ❑Yes ❑ No <br /> "18f�9 N,Demobqt LINDEN CA 95236 Owner Phone#:(209)931-2568 <br /> Opt ncr:�dtlress: t <br /> 'ommunity Facilities Provided by Camn: O Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets <br /> Number of Showers y Number of Lavatories y <br /> Women: Number of Toilets <br /> Number of Showers Number of Lavatories <br /> iousiny Accommodations to be Utilized this Year: <br /> Occunancy Dates: <br /> Buildings Employees '`l r� erf ���LOS <br /> from *,�/��-to-& —1� Crop <br /> Dormitories <br /> from _/_/ to_/_/ Crop <br /> SF Dwellings <br /> Apartments <br /> MH/RV Total Number of Days to be used this Calendar Year: <br /> Owner Owned Total Days Occupied by 25 or more Employees: <br /> Owner Owned RR Cars <br /> Note <br /> MH/RV Spaces <br /> Camps occupied by or more Employees for more days in a year <br /> TOTALS Requiree a PUBLIC WATER SYSTEM <br /> Permit <br /> ❑Inactive <br /> l not be used this year but is intended for use in the future,Check this Box and return this application. <br /> Important: In order to protect your land use status,if camp wil <br /> Fee Schedule <br /> + Number of Employees _ @$12.00 each=$ <br /> Permanent Camp Annual Permit Fe $35.00 $95.00=$ <br /> ❑ Orchard Camp Permit Fee <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ $12.00 each=$ <br /> Permanent Amendment Fee $20.00+ Number of Additional Employees <br /> ❑ $70.00+ Number of Employees (u,$24.00 each=S <br /> Late Application Fee <br /> Fee must be submitted with Application TOTAL FEE DUE$ <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 is 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 Safey Code and Chapter 1,Suhchapter 3,Title 25,Calijnrnii"Codes of Regulations. lO��r ❑ 1'artncr'hip <br /> �iG/,11,rJQl1�D Title n/Qpf <br /> a:pplicaul `;.iunc �/jii/IDto/I/� �.— L;-E'Grporauon <br /> (Please PRINT c, TYPE) ,Q Phone 03��5� <br /> Address �� i/ O/9D UN/JiP/Y �� �SoZ 3l0 _e_4 — <br /> Date of Application <br /> Applicant Signature --- — _. --- <br /> Lii <br /> I01 D � �D Program Record IDP/E Assigned toPWS ID <br /> 2755 1522-VAN BUREN N/A <br /> 43 <br /> I� I Application Printed:11/17/2005 <br /> Report#:7066.rot <br />