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Feb-22-05 02:52P P.02 v � PAYMENT San Joaquin CottntN'-Environmental Health Department RECEIVED 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phout: 209468-3420 2 2005 APPLICATION SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ENVIRONMENTAL PERMIT TO OPERATE HEALTH DEPARTMENT EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑ .Nwitipte Years(Permanent Horning C'anom only) ❑Annaat Permit far C:atendar Yea1 - �� ❑Amended Permit: *Change ur Operator *Change of Owner *Change of Operator Address *CI,anRe of Owner Address *Additional Employees Permit ID#: 0000040 PleruC Note ar:v C'urrectitins or Changes in/'ncility/Urerutor lrrfvrntc7tivq directly on this C amp ID#: 39000054 Site Name- LINDEN ORCHARDS 39-54 I.ocation; 21100 E FRAZIER RD,LINDEN Operator: A SAMBADO&SON i•talling Address: 8077 N TULLY RD,LINDEN CA 95236 Facility Phone fs:(209)931-2568 New Owner, ❑Yes ❑ No Legal 0++11er: 130GGIANO FAMILY INTEREST Owner Address: 7899 N DE MARTINI LN,LINDEN CA 95236 Ownet'Phone ff:(209)931 3086 C pmmunlh Facilities Provided by Camp: Community Kilchem" ❑ Yes ❑ No }ten: Number of l'oilets b Number of Shower's Number of 1 pvarnrirs 16 Women: Number of Toilets N,nnher of Showers `umber of Lavatori,s Ilousin ncrnnunndatimts to he I�tilired this Year. tyccttoancy DaJ Buildin vs Employees /+ Do mib,nes I'rnm .3/ �_l_,_/_ w_/�i, O Crop C r r ica 0 )G $ tiF Dwellings lion, _r_/_.. u, / . ./—_•-- Crop Apartments )weer Owned M I I/RV total Nntttbel'of nays to he used this Calendar Yew: a $C owner Owned RR Cars Total Days Occupied by 25 or n,nre Fmployees: MH/RV Spaces Note TOTALS {�—� Camps occupied by 25 or more Employees for 50 or more days In a year Require a PUBLIC WATER SYS'CFM Permit ❑Inactive jp]pot•tant_ In order to protect ynur 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. Fee Sched,* Permanent Camp Annual Permit Fe $35.00+ Number of'Employees 0 $12.00 ea,:h-S O 0 ❑ Orchard Camp Permit Fee S95.00-S ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20,00+ Number of Additional Employees Ct+1$12.00 ea':lt-S ❑ Late Application Fee $70.00+ Number or Employees tad S24.00 eat:h=$ Fee must be submitted with Application TOTAL EEE;DUES Romlt TOTAL BCE as CALCULATED ABOVE In the ENCLOSED Self•adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary Inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this F roject(camp)shall be operated and maintained In accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Dlvillon 13 of the Cagvrnia Health and Sojay Coda and Chapter 1,Subchapter 3,Title 25,Caf{famiu Code ofRt ulaftntrs. Applicant Name �4 w r�11C SQiyy��GtlJlr> Title Pr C g e n fi ❑Partnership (Aftm PRutrorrrFq Cotporadon Address 77 X• TIN E4 i A st 04 2S2 34 Phone • 9,3/--� 5_L�' Applicant Signature Date or Applie.ttion Amount Paid Date of Payment Payment Type Chac celpt# Received By Account ID �7S•0 �3 D S ✓ If 53 717 I -/'� 0000031 Facility ID Progrdrn Rceord IU PIE Ausigned to PWS ID FA000oom NR0270054 2I55 1522-VAN RI.IRFN WA0504886 Report a toeb rot p�3�O6P' Applir,ati,n Prnted 10/2912004