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Joaquin County-Environmental Health Depar. ,t <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 PAY&1 EN4 <br /> h'ECEIV <br /> APPLICATION 0 13 2011 <br /> I ENVIRONMENTAL HEALTH SAN'Jo <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP H of PMRrk� <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0000040 <br /> *Additional Employees <br /> State ID#: 39000054 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#• 39000054 <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 ❑ No <br /> Owner Address: 7899 N DE MARTINI LN,LINDEN CA 95236 Owner Phone#:(209)931-3086 <br /> Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No <br /> Men: Number of Toilets (D Number of Showers 4 Number of Lavatories CD <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancv Dates: <br /> Buildings Employees A PPLES <br /> Dormitories 18 from 0 a 01/W 11.to la_/31/_@Q1 I Crop C H ER R=ES <br /> SF Dwellings - from _/ / to_/ / Crop <br /> Apartments <br /> Owner Owned p/RV 2 Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS ® Camps occupied by 25 or more Employees for 60 or more days in a year <br /> 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 /> NfPermanent Camp Annual Permit Fet $35.00+ Number of Employees @$12.00 each=$ a H 0 • 00 <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 @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ 75,Q O <br /> Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MAKE CHECKS PAYABLE to EHD <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 <br /> Code of Regulations. <br /> Applicant Name LALJRFNCE 5AM$ADo Title Pp ff9:EM/\ F El Partnership <br /> (Please PRINT or TYPE) /� �Corporation <br /> Address "trf ,� 1 Z'/VQ CA o23(P Phone -9'3 1-Q5LR <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type ChheclIk/Receipt# Received By Account ID <br /> 0000031 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> A0000031 PR0270054 2765 2424-VELOSO-CACAPIT VVA0515762 <br /> H <br /> 2 <br /> Report#:7066.rot ���0,21 / Application Printed:11/2/2010 <br />