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-Joaquin County-Environmental Health Depar+ t <br /> 600 lain Street-Stockton CA 95202-Phone: 209 J1420 pgYM <br /> E <br /> z� <br /> APPLICATION �DU1 <br /> ENVIRONMENTAL HEALTH SAN <br /> PERMIT TO OPERATE ENRo UIN COUN7y <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALT NMENTA <br /> ❑ EPR AIEW <br /> New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for C enndarr Yeear <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 I 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 /> Men: Number of Toilets Number of Showers Number of Lavatories <br /> Women: Number of Toilets Number of Showers Number of Lavatories <br /> Housim!Accommodations to be Utilized this Year: Occupancy Dates: '000A06V <br /> &Jr <br /> Buildings Employees <br /> Dormitories fromAz/A to /?i Xf Crop Cj100"Ieos <br /> SF Dwellings from _/ / to_/_/ Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: a <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 4 ` <br /> [� Permanent Camp Annual Permit Fee $35.00+ Number of Employees � @$12.00 each=$ al''70' • Od <br /> - ❑ Orchard Camp Permit Fee $95.00=$ <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 /> d <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ a j ys <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 /f/!'�� P (X (� Title AeWI01-e i, t G❑],Paartnership <br /> (Please PRINT or TYPE) U=otporation <br /> Address 7 �,QAW 34c= Phone4J(,o�_ fj/".2 Sloe <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> 0000031 <br /> Facility ID Program Record ID PIE J Assigned to �V CS PWS ID <br /> FA0000031 PR0270054 2755 2089-SOOD WA0504886 <br /> Reoort#:7066.rot Application Printed:12/14/2007 <br />