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S, _.,aquin County-Environmental Health Departs RECE 600 E.Main Street-Stockton CA 95202-Phone: 209-46b-�420 � e VE APPLICATION F.NVIRONMENTALHEALTH �GV EN ONMENTAL HEALTH EMPLOYEE HOUSING ORCOUN PERMIT TO LABOR ABOR CAMP SANK 1P,ATE ONP14 �SENT RMIT/SERVICE/S�) ❑New Camp ❑('unditional Permit ❑ Multiple Years(Permanent housing Camps only) anual Permit for Calendar Year (J'/ ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID#: 0000040 *Additional Employees State ID#: 39000054 EH ID#: 39000054 Please Note any Corrections or Changes in Facility/Operator Information direclly on thisJorin. 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 [3] No COR Owner Address: 13Cyr/rl T -- LINDEN CA 95236 Owner Phone#:(209) 9 3 I—oZ5 Communitv Facilities Provided by Camp: Community Kitchen?9 Yes ❑ No NIcn: Number of Toilets to Number of Showers 14 Number of Lavatories to Women: Number of Toilets Number of Showers Number of Lavatories Ilousin Accommodations to be Utilized this Year: Occupancy Dates: Buildings F,mplovecs fromo l / Uorntitories 01/aJa to(off-/3I /�pZ Crop ORC H ARD SF Dwellings from _/_/ to_/_/ Crop Apartments Owner Owned Ml I/RV /� Total Number of Days to be used this Calendar Year: Owner Owned RR Cars total Days Occupied by 25 or more Employees: MI-I/RV Spaces Note ( Camps occupied by 25 or more Employees for 60 or more days in a year TOTALS � 3 I�{ Require a PUBLIC WATER SYSTEM Permit ❑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. Fee Schedule �� Permanent Camp Annual Permit Fe( $35.00+ Number of Employees ct $12.00 each=$ C1"f�r 00 ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ l'ransfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees ct.$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees ti)$24.00 each=$ Fee must be submitted with Application "['O'1'AL FEE DUE$ ,t�D a� Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envellop�cp_�/�t�/Z ( I y 1W?tot� MAKE CHECKS PAYABLE to EI-ID 72 t GTE y,�p� T� 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 raid St fery Code and Chapter I,Subchapter 3,Title 25 Califortia Code of Regttlations. Applicant Name L.A WR ENCE �AM BA DO Title Rz Es z D_T_=K ' El Partnership (Please PRINT or TYPE) - Corporation Address 95 rp�.3 Phone te Applicant Signature Da of Application Amount Paid Date of Payment Payment Type Ch eceipt# Received By Account ID ��7S.D� ��(�� ✓ � �� 0000031 Facility ID Program liercErd ID PIE Assigned to PWS ID FA0000031 PR0270054 111.1 lit) 2765 2424-VELO/SO-CACAPIT WA0515762 21 Application Printed:10/25/2011 Rep #:7066.rpt