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PAYMENT c ,oaquin County-Environmental Health DepartiA. .,t RECEIVED 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 NOV 17 2015 SAN JOAQUIN COUNTY APPLICATION ENVIRONMENTAL HEALTH DEPARTMENT ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp []Conditional Permit ❑ Multiple fears(Permanent Housing Camps only) XAnnual Permit for Calendar Year a 0 142 ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#• 0000040 *Additional Employees State ID#: 39-0054-EH Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000054 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#:(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? 21 Yes ❑ No Men: Number of Toilets 6 Number of Showers J4 Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housin!Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees Dormitories ( from 0L /O[/1(Q to M_/3J( Crop SF Dwellings from / / to /_/ Crop Apartments Owner Owne MH RV Z 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 Nye TOTALS � Camps occupied by 25 or more Employees for 60 or more days in a year ICJ �'i 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 $35.00+ Number of Employees @$12.00 each=$ ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 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,Titl91AMBAD0 California Code of Regulations. Applicant Name LAWRF-NCE t�Title rRESZDEN-17 Partnership (Please PRINT or TYPE) pd Corporation Address W7 LL [„=/V Phone(a0q)93I- Q5(0 Applicant Signature Date of Application Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 7 S 7 C_ G S I U G 0000031 Facility ID Program Record ID PIE Assigned to PWS ID FA0000031 PR0270054 2765 6219-DUNCAN WA0515762 Report#:7066 Application Printed:10/13/2015