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SANI kQUIN COUNTY • PUBLIC HEALTII SERVI 1'IRONMENTAL HEALTH DIVISION y 304 E WFBER AVENUE • TIIIRD FLOOR • STOCKTON CA 95202 • Phone: 209/468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP New Camp Conditional Permit Annual Permit For Calendar Year Amended Permit Multiple Years(Permanent Ilousing Camps on1r) jDate Approved • Change of Operator •Change of Owner jDate Mailed: • Change of Operator Address • Change of Owner Address Illermillft • Additional Employees am p ID N 390 Please Note any Corrections or Changes in Facilili/Operator/Orr'ner lnfbrnnation directly on this form. Site Name: LINDEN ORCHARDS 39-54 Location: 21 10 E FRAZIER RD ----------------------------------------------------—---—----—------------------------------------------------------------------------------------------------------------------------------------__--- —— Operator: JAVIER GARCIA -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Mailing Address: 3431 CARPENTER RD,STOCKTON CA 95215 Facility Phone#: 209-931-3086 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------ Legal Owner: BOGGIANO,J& M New Owner Ycs No� -------------------------------------------------—----- -------------------------------------------------------------------------------------------------------------- Owner Address: 22261 E STOLTE RD, LINDEN CA 95236 �_ Owner Phone#: Community Facilities Provided by Camp: Community Kitchen: Yes No Men: Numbcrof'l'oilets 4 Numberol'Showers Numbcrofl,avatories Lf Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Buildings Employees Buddipgs F.nr,I ccs Dormitories: Owner Owned M11/11V SF Dwellings Owner Owned RR Cars Apartments MII/RV Spaces TOTAL of Both COLUMNS 0 Occupancy Dates: from / / 10 to n_/ �/�Crop y el 'Total Number u Days y be used this Calendar Year from-7/ /p'O to 8 W/U q Crop i+ s � •total Days Occupied by 25 or more Employees Note: Camps occupied hy 25 or more employees for GO or more days a year require a Public Water System Permit. 1 naCtive Important: In order to prolecl 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 z l;J Permanent Camp Annual Permit$35.00+Number of Employees 7 J $12.00 each=$ `1 U 0 I ��M` !_L Orchard Camp Permit Fee=$95.00=$ 1 2 -j 'Transfer of Ownership=$20.00=$ Permit Amendment=$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: RF,MIT TO'I'AI.FFF As CAI.Cl ABOVE IN TIIF,ENCLOSED self-a(I(I ressedENVELOPE. MAKE.CHECKS PA1ABLE TO: PHS/EHD Applicant agrees to all necessary inspections incident to issuance of a PERrun i'O OPERATE,. Applicant agrees that this project(camp)shall be operated and maintained in accordance with the applicable provisions of the EmpLoITE HOUSING ACT,Chapter 1,Part 1,Division 13 of the Health and Safely Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. ft f, y_(50-7 7 Applicant Name pp 1-h c[Q1r1 LJY G -wA �[li''11�t,d/� Title 1�' Partnership Corporation (I'lease PRINT or7Yl'E) Add ss al/00 �• '? r/' f1c] Phone 93l—Q54b Applicant Signature Date of Application e�►�,� �u u it Program RecordW 270054 Facility ID# 000031 Account ID# 0000031 Amount Paid Date of Payment Pa ment T e Check/Receipt# Received B U 0/, -oU Employee#: Acct#: Fac ID: PR#: P S D#: P/E: