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San Joaquin County-Public Health Servic PAYM E-N i Environmental Flealth Division RECEIVED 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 t APPLICATION ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY PERMIT TO OPERATE PUBLIC HEALTH SERVICES EMPLOYEE HOUSING OR LABOR CAMP ENVIRONI,ARITAI HEALTH 0IVIS10N ❑New Camp ❑ Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ElAnnual Permit for Calendar YearZ- ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: 0000040 Please Note any Corrections or Changes in Facility/Operator Information directly on this I Camp ID#: 39000054 Site Name: LINDEN ORCHARDS 39-54 [ Location: 21100 E FRAZIER RD, LINDEN Operator: ne 1 1 ct--co Y 1U Mailing Address: 8077 N TULLY RD,LINDEN CA 95236 Facility Phone#:(209)931-8096r- 13 L-a-S 06 Q -�v-- Legal Owner: �jp iCiY�� FC�1Vh ,vY- Ce-'A- New Owner? ❑Yes No Owner Address: 7899 N DE MARTINI LN,LINDEN CA 95236 Owner Phone#:(209)931-3086 Communitv Facilities Provided by Camp: Community Kitchen: IZYesNU Men: Number of Toil _�� Number of Showers "Number of lavatories Women: Number of Toilets Number of Showers Number of lavatories _ Housine Accommodations to be Utilized this Year: Occupancy Dates: _ Buildings Employees from/ GL-to /p!-Crnp Dormitories from_/_/_to_/_/_Crop SF Dwellings �) Apartments Total Number of Days to be used this Calendar Year Owner Owned MH/RV Total Days Occupied by 25 or more Employees Owner Owned RR Cars Note: MH/RV Spaces Camps occupied by 25 or more employees for 60 or more days in a year TOTALS require a Public Water System Permit, r f ❑ 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. 1,1 Fee Schedule v 0/permanent Camp Annual Permit Fee: 535.00+ Number of Employees @ $12.00 each=$ G t7 l7 ❑ Orchard Camp Permit Fee: $95.00= Transfer of Ownership: $20.00=$ ❑ Permit Amendment Fee: b20.00+ Number of Agional Employees @ $12.00 each=$_ Late Application Fee: $70.00+ Number of Employees @$24.00 each=$ Fee must be Q.Ittd with Application q TOTAL FEE DUE: $ Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-Addressed Envelope MAKE CHECKS PAYABLE TO: PHS-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,Title 25,California Code of Regulations. Applicant Name � `N�, S7 �� Title El Partnership (Please PRINT or TYPE) G;- corporation Address N Phone 9 '1-1 'j 11& _ Applicant Signature 11- Date of Application 3--6 0 z Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID 0000031 Facility ID Program Record ID PIE Assigned to PINS ID 0000031 0270054 2755 1522-VAN BUREN 0000040 Report#:7066.rpt Application Printed:11/19/01