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S. oaquin County-Environmental Health Departn RECEIVED <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209-46t,420NT <br /> APPLICATION .a �vis <br /> viaENVIRONMENTAL IIEALTII ENONMENTAL HEALTH <br /> PERMIT TO OPERATE EMPLOYEE HOUSING OR LABOR CAMP SW 30 RpNMEN EN1 COUrA RMIT/SERVICES <br /> EN pEPAF <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent housing Camps only) Ht�VLnnual Permit for(':dendar\'car <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0000040 <br /> *Additional Employees State ID#: 39000054 <br /> EH ID#: 39000054 <br /> Please Nole any,Correclkms or Changes ill FacilitY Operator ln(ornulfion directly on thisJorm. <br /> Site Name: LINDEN ORCHARDS 39-54 Location: 21100 E FRAZIER RD,LINDEN <br /> Operator: A SAMBADO&SON <br /> Mailing Address: 8077 N TULLY RD, LINDEN CA 95236 Facility Phone#:(209)931-2568 <br /> Legal Owner: BOGGIANO FAMILY INTEREST New Owner? ❑Yes [3"No <br /> Owner:Wdress: $fir'1'7-F %:�LINDEN CA 95236 Owner Phone#:(209) (Q 3 1—Q <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets �p Number of Showers N Number of Lavatories t0 <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Kmaloyms <br /> _ fromo l /O l/�Q to 1 a/31 /9 Crop ORS H ARD <br /> SF Dwellings from _/_/ to / / Crop <br /> Apartments <br /> Owner Owned -1/RV — /� Total Number of Days to be used this Calendar Year: <br /> ,I <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> � Camps occupied by 25 or more Employees for 60 or more days in a year <br /> TOTALS <br /> 1=•J ��{ Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> 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. <br /> Fee Schedule <br /> VLPermanent Camp Annual Permit Fe( $35.00+ Number of Employees _CJgJD_1L�a $12.00 each=$ &40,OP <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ "Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees a.$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @t $24.00 each=$ <br /> Fee must be submitted with Application any.10U <br /> TOTAL FEE DUN:S <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE,CHECKS PAYABLE to EIID <br /> Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1, Part 1,Division 13 of the California Health <br /> and Safety Code and Chapter 1,Subchapter 3,Title 25 California Code of Regulations. <br /> Applicant Name LA WR ENCE SAM BA DO Title t pr�tirr- ❑ Partnership <br /> (Please PRINT or TYPE) Corporation <br /> Address 9523to1'hun OG1� C�`�(_ spa <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type CherktReceipt# Received By Account ID <br /> 0000031 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0000031 PR0270054 2765 242 -VELOSO-CACAPIT WA0515762 <br /> An <br /> Report#,7066 rot Date 2 /z Application Printed:10/25/2011 <br /> ��ZlJ� zL lv�olp3 <br />