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r San in County-Environmental Health Department `�tV Q•��' 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-4.58-3420 D �a gpN JOAaUIy L� APPLICATION , r i L ENVIRONMENTAL HEALTH ;J �� ENVIFIONMEN T PERMIT TO OPERATE Ep,LTH OEQPRTMEN EMPLOYEE HOUSING OR LABOR CAMP N Annual Per for Crq ,,daF year ❑New Camp ❑Conditional Permit ❑ multiple Years(Permanent Housing Camps only) ❑ 1.��F-,';,. . ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#• �90( c ease Note arty Corrections or Changes in Facility/Operator Information directly on this Camp ID#: J� .39 Location:all®® .�r+1l�t� RD,LINDEN Site lame: �/✓f e1 e,Pp ©r�hQ. Operator: A SAMBADO&SON INC 71 Facility Phone#:(209)931-2568 flailing Address: 8077 N TULLY RD,LINDEN CA 95236 ��db�,� T�,�`V`♦� New Owner? El Yes ❑ No Le. wner: ®��j 1 A V►t�N,DtMp� LINDEN CA 95236 (lArnerl'hnnc ! (209)931-2568 Add Address: ��r 'ommunity Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Number of Showers Number of Lavatories Men: Number of Toilets Number of Lavatories Women: Number of Toilets Number of Showers lousin Occupancy Dates:Accommodations to be Utilized this Year: n Buildings Employees ''/_ �r/ze/rs' from to 1Li1—i��c Crop Dormitories _/_/ Crop from _/_/ to SF Dwellings Apartments Total Number of Days to be used this Calendar Year: Owner Owned MH/RV Owner Owned RR Cars Total Days Occupied by 25 or more Employees: Note MH/RV Spaces Camps occupied by or more Employees for more days in a year TOTALS Re°uire a PUBLIC WATER SYSTEM Permit ❑Inactive if camp will not be used this year but is intended for use in the future.Check this Box and return this application. Important: In order to protect your land use status, Fee Schedule 91 Permanent Camp Annual Permit Fe $35.00+ Number of Employees _ @$12.00 each=$ e7 yo • d� ❑ Orchard Camp Permit Fee $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ @$12.00 each=$ Permanent Amendment Fee $20.00+ Number of Additional Employees 71 Late Appiicarien Fee $70.00+ Number of Employees la;$24.00 each=S Fee must be submitted with Application TOTAL FEE DUE$ e"5, Q d 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''->,Califor,ia Curie alRegulrrtions. D Title ❑ I'aruxratip Applic:rul '::,nrc /�ctJRtl?NCE �14rnbQa� — L;.E'urpo,.,tton (Please PRINT To, TYPE) � Phone Address �tZQ - �3/o�•S��' Date of Application - Applicant Signature - ----- -- __ — - -- _ - 000-8+7115 31 Facilit�ID Program Record tD P/E Assigned to PWS ID FA00) PR6z 8321 2755 1522 VAN BUREN N/A Application Printed:11/17/2005� Report#:7066.rpt