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1 <br /> .,aquin County-Environmental Health Depat RECEIVED <br /> Qp��`CJE� 600 E.Main Street-Stockton CA 95202-Phone: 209468-3420 <br /> R�G� �• fah <br /> APPLICATION <br /> Yo ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE ENVlRONMEc��A%ICHEALTH <br /> ate' EMPLO ES <br /> YEE HOUSING OR LABOR CAMP PERM/j <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar YeaF 96 f / <br /> [:]Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0002797 <br /> *Additional Employees <br /> State ID#: 39-0040-EH <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this form. <br /> EH ID#• 39000040 <br /> Site Name: PEARCE,JEFF H 39-40 Location: 5125 S KAISER RD,STOCKTON <br /> Operator: PEARCE,JEFF H <br /> Mailing Address: 1680 INDIAN VALLEY ROAD,NOVATO CA 94947 Facility Phone#:(415)898-8052 <br /> Legal Owner: PEARCE,JEFF New Owner? ❑Yes No <br /> Owner Address: 1680 INDIAN VALLEY RD, NOVATO CA 94947 Owner Phone#:(415)60 -1527 <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 /> Housing Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from �/ � / I`1 0z/3/// V Crop <br /> SF Dwellings from _/_/ to / / Crop <br /> Apartments S <br /> Owner Owned MH/RV �— Total Number of Days to be used this Calendar Year: <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: OQ <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 1r- <br /> Permanent Camp Annual Permit Fe( $35.00+ Number of Employees @$12.00 each=$ <br /> ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> n Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ I.ate Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ <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:and <br /> Safety Code and Chapter 1,Subchapter 3,Title 25,California Code of Regulations. <br /> Applicant Name JfL O/1�� C.t� Title 601 A.,4 'L ❑Partnership <br /> (Please PRnVI or TYPE) ^' ^� ❑Corporation <br /> Address 1 0(/v ." ,kj �//�C'4� /�' V011 01 tt 7 7 Q[�5 CS/ Phone <br /> Applicant Signature ' Date of Application 4?10-1/,3 <br /> Amount Paid Date of Payment Payment Type Che eceipt# Received By Account ID <br /> 0002366 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0002805 PR0270040 2765 8987-SANGALANG WA0461354 <br /> Report#:7066 Application Printed:1 011 7/2 01 3 <br />