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4W 12/23/2003 13:22 46401' ENVIRONMENTAL �LTH PAGE 02 <br /> San Joaquin County-Environmental health Department <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP h <br /> New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year yo <br /> ❑Amended Permit: *Change of Operator *Change of Owncr <br /> *Chartre of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit fA#: 0000040 <br /> Please Note any Corrections or Changes In Facility/Operainr Information directly on this Camp ID#: 39000054 <br /> Site Name: LINDEN ORCHARDS 39-554 `_ 1 c Location: 21100 E FRAZIER RD,LINDEN <br /> Operatnr: A I JQ 1M p V.p JO✓1 <br /> Mailing Address: 8077 N TULLY RD,LINDEN CA 95236 Facility Phone#:(209)931-2568 <br /> Legal Owner: BOGGIANO FAMILY INTEREST New Owner 7 ❑Yas [] No <br /> Owner Address: 7899 N DE MARTINI LN,LINDEN CA 95236 Owner Phone#:(209)931-3086 <br /> Community Fatilitics Provided by Camp.- Community Kitchen 7 ® Yes LJ No <br /> Men: Number of Toilets Numbcr of Showers A14 Numbcr of Lavatories <br /> Women: Number of'foilets Numbcr of Showers Number of Lavatories <br /> HoutineAtcommndations to bt Utili etl this Year: Oeeunancv Dates: <br /> Boilditl�,Y Rmnloyccs <br /> Dormitories from .3/ l d 4(to l f l l 1' Crop C'h��t ��� tee <br /> SF Dwellings from _/_/ to_/�/ Crop • <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: O� <br /> Owner Owned RR Cars Total Days Occupied by 25 or mote Employees: <br /> MH/RV Spaces <br /> TOTALS a <br /> Camps nccupied by 25 or more Employees for 60 or ntore days in a year <br /> Require a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> Intnortafyt: In order to protect your land wit status,if camp will not be used this year but is intended for tee in the future.Check this BoA and return this application. <br /> Fee Scliedule O o 0 <br /> [] Permanent Camp Annual Permit Fe T .00+ Numbcr of Employees a Cal$12.00 each=$ <br /> ❑ Orchard Camp Permit Fee $85,00 S <br /> ❑ Transfer of Ownership $20.00=$ <br /> [] Permanent Amendment Fee $20.00-1- Numbcr of Additional Employees @$17.00 each-$ <br /> ❑ Late Application Fee $70.00+ Number of Employees @$24.00 cash=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE S <br /> Remit TOTAL.FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope <br /> MARE CHECKS PAYABLE to EHD <br /> Applicant agree*to all necessary inspectiont incident to ittuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated <br /> and maintained in accordance with the applicable prnvisions 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 z5,California Code of Regulations. <br /> Applicant Name /�0—w k-#d1 C. (E � ) Title j-t(S ❑Partnership <br /> (Please PRINT or TYPE) �Corporation <br /> Address t . QS <br /> Applicant Signature Date of Application / <br /> ��M� �►4T� Ppl �l}t�rl1�H'I"� P,� �Nr�i�' It kr e4m l•A by Uf t!tar{-HT /D <br /> F2800rt#:7066.0 Appllpllon Printod:1212312003 <br /> Fl9e-IkI7y ry7 "PKvG m �daeR� 1D F Aaa1 Gx.ED 7'o pw s l D <br /> -PIC oa7�cSy a275� <br />