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-1- <br /> San Joaquin County- Environmental Health Department P/-\\r`IVIEiN <br /> RECEIVED600 E. Main Street-Stockton CA 95202-Phone: 209-468-3420 <br /> APPLICATION SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL.HEALTH ENVIRONMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <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 <br /> 'Additional Employees <br /> Permit ID ft: 0000040 <br /> Please.yore ant Corrections or Changes in Facility/Operator Information directly'on this Camp ID#: 39000054 <br /> Site Name: LINDEN ORCHARDS 39-54 Location: 21100E 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 Y ❑Yes ❑ No <br /> Owner Address: 7899 N OE MARTINI LN,LINDEN CA 95236 Owner Phone#:(209)931-3086 <br /> Communitv Facilities Provided by Camp: Community Kitchen' ❑ Yes ❑ No <br /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housing Accommodations to be Utilized this Year: Occupancv Dates: <br /> Buildines Employees <br /> Dormitories from�3/0-,ia e,& to /2 34 Z491 O crop G',fySPitl Ies <br /> SF Dwellings from '_/ ._to_ ! _ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees. <br /> NIH;RV Spaces Note <br /> TO,rALS L� Camps occupied by 25 or more Employees for 60 or more days in a year <br /> LI 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 /> Permanent Camp Annual Permit Fer $35 00 t Number of Employees C. $12.00 each==S ���• Od <br /> ❑ Orchard Camp Permit Fee $95.00=$ <br /> ❑ Transter 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 d <br /> TOTAL FEE DUE:$ <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 Code of Regulations. <br /> Applicant Name ( �)� �. /`i'K LX (� Title ,�//�1 tl 7 �' ❑Partnership <br /> iPlease PRIN7orrTGTYPE) -- E5'1rUrporation <br /> Address <br /> Q 077 /�(.��j� 3 Phoneao¢ fj/_2 she <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/SSr&.44# Received By Account 1D <br /> 5 - � V 5 4 3 39 � 0000031 <br /> Facility ID Program Record ID P)E Assigned to PWS ID <br /> FA0000031 PR0270054 2755 20 OD WA0504886 <br /> Reoor.-- 7066 rot -A o-fir /,W#0 Application Printed 1 211 4/200 7 <br />