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San Joaquin County-Environmental Health Department <br /> 1868 E Hazelton Ave-Stockton CA 95205-Phone: 209468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP 1 1 <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ® Annual Permit for Calendar Year 2026 <br /> ❑ Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> State ID#: '- <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> Site Name: A SAMBADO&SON 39-370/WTR SYS Location: 15294 E EIGHT MILE RD LINDEN <br /> Operator: A SAMBADO&SON 39-370AVTR SYS Email: <br /> Mailing Address: 8077 N TULLY RD,LINDEN CA 95236 Facility Phone#: (209)931-2568 <br /> Legal Owner: SAMBADO,LAWRENCE J&BEVERLY New Owner? ❑ Yes o <br /> Owner Address: 8077 N TULLY RD,LINDEN CA 95236 Owner Phone#: (209)931-2568 Entail: <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets 440f Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> I►ousinu Accommodations to be Utilized this Year: Occupanev Dates: <br /> BuildinEs Emnlovees �y <br /> Dormitories from l / to / 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,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 Fee $54.00+ Number of Employees e @$17.00 each= <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$l 7.00 each=$ <br /> ❑ Late Application Fee $108.00+ Number of Employees @$34.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE Soi <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-addressed 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 and <br /> Safety Code and Chapter 1,SS bcchaappteerr 3,Title 25,Cali ornia Code of egulations. <br /> Applicant Name 1�SE�'�O�'� Title � ❑Partnership <br /> (Please PRINT ) Co�Jrattiio�n7 <br /> Address � - '`%�%��^ j � jQ? rj Phone G / 91 <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By <br /> Cie cam- <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0013764 R0518217 2765 aron Gooderham <br /> Report#:7067.rpt RECEIVED <br /> DEC 2 2 2025 <br /> ,;AN JOAOUIN COUN I <br /> ENVIRONMENIAI <br /> IrAI TfI UI'PAP 1 r <br />