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Feb-22-05 02:52P P.02 ' PAYMENT San.loaquin Count'-F..Itvirorintental Health Department RECEIVED ,104 E Weber Avenue-Third Floor-Stockton CA 95202-Phnne: 209-468-3420 APPLICATION SAN JOAQUIN COUNTY ENVIRONMENTAL HF.AI:rH ENVIRONMENTAL PERMIT TO OPERATE HEALTH DEPARTMENT EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing('an-Ph ortty) ❑Annual Permit row Calendar Year �- ❑Amended Permit: *Change r)tl),terator `Change of Owner *Change of Operator Address *(:haoge of Owner Address *Additional Employees Pcrtnit ID#: 0000040 Please,Vote mtV Corrections or C:JhirlGCs it;1713eility/lJperu/ur lnJorntcrtiat rfirecrly on this Larne ID T. 39000054 Site Name- LINDEN ORCHAIRDS 39-54 Location: 21100 E FRAZIER RD,LINDEN Operator: A SAMBADO&SON INN III tig Address: 8077 N TULLY RD,LINDEN CA 9523E Facility Pho1iet7:(209)931-i568 Legal Or+tier: BOGGIANO FAMILY INTEREST New Owner'! ❑Yes No Owner Address: 7899 N DE MARTINI LN,LINDEN (,A 95236 owner Phone#:(209)931.3086 Comurunln Facilities Provided by Camp: Community Kitchen'' ❑ YPs ❑ No }feu: Number of'I'oilets Number of Showers Number or I at'atniirs Women: Numhcr nf'rnilcta Nrtmhcr of Showers `umber of Lavam it S IIt,uwin Lyle cmmmndatinits to be Utilized this Ycar: gaERKE:I Doi FiuittlirtPs t:mnloyccs INwinturies from ('rap C�ar r ICJ It:S SF 1lwOlinga T� lium _r /_ hr Apartments ')wner Owned MFI/RV Total Number of Days to he used this Calendar Yea,: a,$ )wnt:r O.vnt:d RR Cars 'Total Days Occupied by 25 or more Fmployees: MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for more dayt In a year Require a PUBLIC WATER SY$'rRM Permit ❑Inactive Important! in under to prutcct your lanai use status,if camp will not be used this year but is intended for use in the future,Cheek this Box and return this application. Fee Schir4ok Permanent Camp Annual Permit Fe S35.00+ Number of Employees 0Z 0 a $12.00 car:h a-S o? ❑ Orchard Camp Permit Fee S95 00-S ❑ Transfer of Ownership $20 00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees t! $12.00 eaAi-S ❑ Late Application Fcc $70.00+ Number of Employees ®S24,00 ea,:h=S Fee must be submitted with Application TOTAL FEE:DUES -� 7.S. 0 0 Remit TOTAL BEE as CALCULATED ABOVE in the ENCLOSED Self-&dressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary Inspectionv incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this f reject(camp)shall he operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACI',Chapter 1,Part 1,Divi iron 13 of the COifornia Health and Safety bode and Chapter 1,Subchapter 3,Title 25,California Code ofRegaladons. C S r e n Applicant Manx ��ty� ,� Sb�At� Title Partners,� `pt 't'_ __ ❑ � (Picric MmrorTrPq Corporation Address 'f �Y. 1` e,#. q-C2 3L Phone Applicant Signature Date of Applie.ttion Amount Pald Date of Payment Payment Type CneeW;W;Il t/t Received By Account ID �.275,-D ,23 D S ✓ �5 000003137`7 —J . Facility ID Pro9rartt Rcoord ID WE Assiynud Io PINS ID FA00000m PR0270054 2755 1522-VAN RI IRFN WA0504086 Reoort* /o®a rut Application?!,rated 10/2912004