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SAN JOAQUIN COUNTY • PUBLIC HEALTH SEIsLICES ENVIRONMENTAL HEALTH DIVISION 304 E WEBER AVENUE • THIRD FLOOR • STOCKTON CA 95202 • Phone: 209/468-3420 APPLICATION ENVIRONMENTAL HEALTH PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP ElNew Camp ❑Conditional Permit 117 Annual Permit For Calendar Year ❑Amended Permit ❑Multiple Years(Permanent Housing Camps only) =# 000040 Approved • Change of Operator *Change of Owner • Change of Operator Address • Change of Owner Address • Additional Employees Please Note any Corrections or Changes In FaciWlOperatoriOwner Information directly on this form. Site Name: LINDEN ORCHARDS 39-54 Location: 2110 E FRAZIER RD Operator: JAVIER GARCIA Mailing Address: 3431 CARPENTER RD, STOCKTON CA Facility Phone#: 209-931-3086 ---------------------------- - --------------------------------------------- ------------------------------------------------------------------ Legal Owner: BOGGIANO,J&M yew owner ❑Yes Nq Owner Address: 22261 E STOLTE RD,LINDEN CA Owner Phone#: Community Facllitles Provided by Camp: Community Kitchen: $1 Yes 11 No Men: Number of Toilets Number of Showers_— Number of Lavatories Women:Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Building s Employees Bu� �� Dormitories: C Owner Owned MH/RV SF Dwellings Owner Owned RR Cars Apartments MH/RV Spaces TOTAL of Both COLUMNS O Occupancy Datesp _ from�% / Q7 to 7��, / q�1 CYrop .� 1 � Total Number of Days to be used this Calendar Year from / to -Li / 4 Crop AnD�S. nfA1 S Total Days Occupied by 25 or more Employees Note: Camps occupied by 25 or mare employees for 60 orrmore dgps a yarn require a Pabltc Water System Penn& ❑ Inactive Inmorlanl. In order to protect your land use status if canip will not be used thzs year but Is Intended for arse In tbe,Jidnn, Ckeck this Box and return this apptieadoa Fee Schedule LK Permanent Camp Annual Permit$35.00+Number of Employees 3 $12.00 each=$ ❑ Orchard Camp Permit Fee=$95.00=S ❑ Transfer of Ownership=$20.00=S ❑ 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: REMIT TOTAL FEE AS CALCULATED ABOVE IN THE ENC703ED self-addressed P,NVEI,OPE. 1MAjw CmLvrxSPAPABLETo. 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 xousiNG ACT, Chapter 1,Part 1,Division 13 of the Health and Safety Code and Chapter 1,Subchapter 3,Title n,California Code of Regulations. Applicant Name L, f�� J _ 1-e +r-� (3AV j�^"�A�Titie �� ' r ❑Partnership ❑Corporation (Please P=6r TYPl) Address �� - ' — ? 1`:_ , ------- ----- Phone_ Applicant Signature _ " Date of Application Program Record lD#A Facility ID# 000031" Account 1D# 000-0031 &41,q Fee Anx nt Amount Paid Date of Payment Payment Type I Oie&Yltecelpt# Received By C10 1 -0-0 g0t• Coo 5 1 _ Employee#: Acct 9. Fac ID: PR# S ID#: PiE: LZYbZ 7 5.-