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S 'oaquin County-Environmental Health Departr <br /> 600 L. ain Street-Stockton CA 95202-Phone: 209-4 420 <br /> F�EC%� <br /> APPLICATION DEC 3 1 Z008 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE SAN JOAQUIN COUNTY <br /> EMPLOYEE HOUSING OR LABOR CAMP ENVIRONMENTAL <br /> �ALYH DEPARTMENT <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Cal ar ear <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 0000040 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this Camp 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 /> Nlen: 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: Occupancy Dates: <br /> Buildings Employees of o( d !Z 3 1 09 C P�L�os <br /> Dormitories from!>3/A/_0�[to/.' / / p Crop L4 hw/Pj!/01 $' <br /> SF Dwellings from _/_/ to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 423 Q <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces <br /> 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 'e ''// <br /> Permanent Camp Annual Permit Fe( $35.00+ Number of Employees @$12.00 each=$ .9 7� <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$ p775_ <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 �l�(y�',e/f� S,y�jn�j'aQ(p Title ����1,jAO�T ❑Partnership <br /> (Please PRINT or TYPE) Corporation <br /> Address77 Al. rajeV 1rV.4.0 lel"gvW L14.4 gsa 3 Phone, 93/ -.,7 S 6$ <br /> Applicant Signature Date of Application <br /> Amount Paid r Date of Payment Payment Type Chel #ck/Reesiml Received By Account ID <br /> oa ( 5 V,L 1 S I / 6 1E �,b L W;_ 0000031 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0000031 PR0270054 2 5 1421 -RIVEFtK— WA0504886 <br /> W I r S c:rvlK-+'L <br /> Report#:7066.rpt Application Printed:10/30/2008 <br />