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PAYMENT <br /> San Joaquin County-Environmental Health Department RECEIVED <br /> 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 DEC <br /> 2 9 2021 <br /> IN <br /> APPLICATION EN IRO M COUNTY <br /> HEALTH DEPARTMENTT <br /> ENVIRONMENTAL HEALTH <br /> Aw PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP 1 <br /> ❑New Camp E] , <br /> Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) `{,[I Annual Permit for Calendar Year (R oa 0 <br /> ❑Amended Permit: *Change of Operator *Change of Owner 117��� <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0000040 <br /> *Additional Employees <br /> State ID#: 39-0054-EH <br /> Please Note anv Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000054 <br /> Site Name: LINDEN ORCHARDS 39-54 Location: 21100 E FRAZIER RD,LINDEN <br /> Operator: A SAMBADO&SON <br /> Mailing Address: 8077 N TULLY RD,LINDEN CA 95236 Facility Phone#:(209)931-2568 <br /> Legal Owner: BOGGIANO FAMILY INTEREST New Owner? ❑Yes ❑ No <br /> Owner Address: 7899 N DE MARTINI LN,LINDEN CA 95236 Owner Phone#:(209)931-3086 <br /> Community Facilities Provided by Camp; Cvnununily Kitchen? u Y�� ❑ iJo <br /> Men: Number of Toilets to Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> BuildinLy Employees <br /> Dormitories from 0W 36 a to 1a/ 3p-aa 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 <br /> 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 $50.00+ Number of Employees RO L$15.00 each=$ 300, O D <br /> ❑ Transfer of Ownership $25.00=$ <br /> ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees L$15.00 each=$ <br /> ❑ Late Application Fee S100.00+ Number of Employees L$30.00 each=$ <br /> Fee must be submitted with Application _ <br /> TOTAL FEE DUE <br /> Remit TOTAL FEE as CALCULATED A ROVE in*he E NCLOSEv Selt-adressed 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 <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25,Ca��A <br /> nia Code of Regulations. <br /> Applicant NameTitle ❑ Partnership <br /> PP L A(�RFU�I'CE' MBA(L R��. OI�/lJ��` p <br /> (Please PRINT or TYPE) Corporation <br /> AddressIN. 5 gap Phone D nq - <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/ eceipt# Received By Account ID <br /> 3 50r l t 1 I� 2 Q Z` 0000031 <br /> V <br /> Facility ID Program Record ID PIE Assigned to PAIS ID <br /> FA0000031 1 PR0270054 2765 3611 -GIRARDI WA0515762 <br /> Report#:7066 Application Printed:12/16/2021 <br />