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•, ." vuii vvuyu In vv U II rY <br /> 10, U bI /vAw <br /> San Joaquin County-Environmental Health Dep, ent Pq r`WEFIVT <br /> I t_,G.Hazelton Avenue-Stockton CA 95205-Phone: 209-468-3420 f?ECfFI <br /> VEp <br /> JA N n Q <br /> APPLICATION S <br /> ENVIRONMENTAL HEALTIl A ENVI OVIN COl/ <br /> PERMIT T[3OPRRABOR etuc HEATHHOPARTA�N� <br /> EMPLOYEE Nt111SING MENT <br /> ❑Nea Camp q Coadltlonni Permit p Dlulllplr]'oars(Ycrmnncnt Housln _ <br /> ❑Amended P erinil: "Change of Operator " • C Cinnps only) �.nnual Permit for Calendar Year �°Ghangc of Owner � L. <br /> "CbangeofOpora for Address "Cha age orU»ner Add ress <br /> 'Additional Employee Permit ID N: 0000040 <br /> State ID#' 3940)054-Eli <br /> Please Ilrote any Correcllons or Changes in Fac111g1/0 Irotor frfornration direclly orl this jonu. EH Ill ft, 39000054 <br /> Site Dianne: LINDEN ORCHARDS 39-54 <br /> Locaflon' 211011 E FRAZIER RI),LINDEN <br /> Operator: A SAMBADO&SON <br /> ,flailing Address: 8077 N TULLY RD,LINDEN CA 95235 <br /> Facility Phonc N:(209)931-2868 <br /> rLL,gal Owner. BOGGIANO FAMILY INTEREST <br /> Now Owner? ❑Yes No <br /> nerAddress: 7890 N DE MARTINI LN,LINDEN CA 95236 <br /> Community Facilities hrnvld•rl t Otvner Phone h:(209 931-308$ <br /> Cantu Community Kitchen? R Yes ❑ No <br /> 111cn; Numbcr of Toilets Number of Showers Women: Number of Toiicls '? Number of Lavatories <br /> Numbcr of Showers Numbcr Of Lavatories <br /> HmnsinY Accommodotlnna _he n•ilized this] a <br /> OccuA$I1C]:.l)81.Oi <br /> B II,�ItI_Ine, LntIL)= <br /> Dormitories J_ oil <br /> SF Dwellings diem D � Ioa,31/J-5 Crop <br /> front Crop <br /> Owner Ott na RV Total Number of Days to be used Ihis Celendur Ycar, <br /> Owner V ned SpaSpacess e Cars <br /> MR/RV10(al Days Occupied by 25 or more Employees: <br /> TOTALS Camps occupied by 25 or more Et"Ployces for 60 or more days In a year <br /> ❑inactive kcqulre a PUBLIC M'A7'Ett 5'YSTEM Permit <br /> i <br /> Important• In order to protect your land use status,if camp will not be used this3 ear bill is intended for ugt;in the future,Check this Box asxi rrlum this application. <br /> ee Rrh &dine / <br /> Pemtaucnl Camp Annual Per-mil Fe, $35.1)U+ TNumbcr of)employees ��lJ , <br /> [f Orchard Camp Permit Fee S12.00 each—$ <br /> [) TransferufOttnership Numbcr of Employees $95 00_$ <br /> ❑ Permanent Amendment Fee $20.00+ $20.00 $ <br /> Number of-Additional Employees 0 @$12.00 each=$Late Application $70.00+ Number off=mployces <br /> Fee must be Submitted with ApplicAtlolt Cqi$24.00 each=$ <br /> TOTAL FEE DUE S <br /> Rentil l'OT'AL FEE as CALCULATED AUO]'E In the ENCLOSED Self-adrrsscd Enuctope <br /> f1A10E CHECKS PAYABLE to EHD <br /> Applicant agrees to all necessary inspeclions Incident to Issuance of n PERMIT TO OPERATL Applicant agrees that Ihis project(camp)shall be operatetl <br /> and afety odened In Chnfiancc wllh the applicable fnovisions o!the E,NIPLOVEE 110USiNI G ACT,Chapter 1, part 1,hlvlslmt 13 of the Cbl1forula Heallb <br /> and Safety Code and Chapter 1,Subchapter 3,'fills 25,Call o-r`nla Code of ft,/rations. <br /> Applicant Name L A Ll_R NC oIAM BAC)(� Title <br /> (Plciafe PRINT iv rypE'I ESZ'D�>UT ❑Partnership I <br /> Address TtlLL D LAN Corporation <br /> p Phone C <br /> Applicant Signaturewoe —o� <br /> Date ofApplieation — 1— 15 <br /> Amount Paid Date of Payment Payment Type Check/Receipt tl <br /> �" Received By 4..,uonD <br /> l/� ✓ 4,FacilityID Program RecordID PIE <br /> F'A0000031 Assigned to <br /> PR0270054 2765 2424-VELOSO <br /> WA0515762 <br /> Retwtt 9.,706c <br /> ADolicsatlon Pruned,1r7i201S <br />