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Sai.-,taquin County-Environmental Health Departme� . PAYMENT 1868 E.Hazelton Avenue-Stockton CA 95205-Phone: 209468-3420 RECEIVED APPLICATION ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY PERMIT TO OPERATE ENVIRONMENTAL EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year_ate a I ❑Amended Permit: "Change of Operator "Change of Owner "Change of Operator Address "Change of Owner Address Permit 1D#: 0000040 *Additional Employees State ID#: 39-0054-EH Please Note any Corrections or Changes in Facility'Operator Information directlYon thisform. 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? ❑ Yes ❑ No Men: Number of Toilets Lr Number of Showers —{ Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to he utilized this Year: Occupancy Dates: Buildings Employee Dormitories � from QL/0/ gV to Q/31/ 010 Crop ` SF Dwellings from _/_/ to_/ / Crop 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 -Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive Im op rtant: 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 r� Permanent Camp Annual Permit Fee $50.00+ Number of Employees Qn n$15.00 each=$ J Q ❑ Transfer of Ownership $25.00=$ ❑ Permanent Amendment Fee $25.00+ Number of Additional Employees t$15.00 each=$ ❑ Late Application Fee $100.00+ Number of Employees 5 $30.00 each=$ Fee must be submitted with Application TOTAL FEE DLtE$ 3_�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 HORSING .ACT,Chapter 1, Part 1,Division 13 of the California Health and Safety Code and Chapter 1,Subchapter 3,Title 25 California Code of Regulations. Applicant Name LA WR ENCE �A M BADo Title P�P _S, J(DWtj67� ❑Partnership (Please PRINT or TYPE) i Corporation Address L, /�' 5QB Phone _ SiQ56t Applicant Signature ov oc Date of Application e a- �'7- as Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID q n rn 4/ ' 1-1 i n —* —1 9,'19 0000031 Facility ID Program Record ID v( P/E Assigned to PWS ID FA0000031 PR0270054 2765 9819-BENIAMINE WA0515762 Ronnrt it 7nRR Application Printed:11/13/2019