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Joaquin County-Environmental Health Department 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 PAYMENT RECEIVED APPLICATION NOV 2 L 2017 ENVERONMENTAL HEALTH SAN 3OAQUIN COUNTY PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT Q ❑New Camp [-]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year a o i T) [:]Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID N: 0000040 *Additional Employees State ID#: 39-0054-EH EH II)#: 39000054 Please Note any Corrections or Changes in Facility/Operator Information directly on this form. Site Name: LINDEN ORCHARDS 39-54 Location: 21100 E FRAZIER RD, LINDEN Operator: A SAMBADO&SON Mailing Address: 8077 N TULLY RD, LINDEN CA 95236 Facility Phone M(209)931-2568 Legal Owner: BOGGIANO FAMILY INTEREST New Owner? ❑Yes No Owner Address: 7899 N DE MARTINI LN,LINDEN CA 95236 Owner Phone#:(209)931-3086 Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets Number of Showers 4 Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this bear: Occupancy Dates: Buildings I":mploNees Dormitories from 0/01 JO to-al-ab1 Crop O- SF Dwellings from / / to_/ / Crop v Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Nflk TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year 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 ^ Permanent Camp Annual Permit Fee $50.00+ Number of Employees «� @$15.00 each=$ 30 o• Q O ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees @$15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application TOTAL FEE DUES 3 5 0. 0 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 31 Title 255 California Code of Regulations. Applicant Name LA W RENCr: &M RAba Title RF'CST��`1- /D W&IF ,❑,Partnership (Please PRINT or TYPE) & I4.Corporauonn Address W rl7 I V. -FLLL�.Y D.? LxN DEN _O-A Q�3(0 Phone �Q \�� Applicant Signature Date of Application I•o_31- Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 11 3 _ \ ' l /as / ! C L � G 7 � 0000031 Facility ID Program Record ID P/E ( Assigned to PWS ID FA0000031 PR0270054 2765 6219-DUNCAN WA0515762 Report# 7066 Application Printed:10/23/2017