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i Joaquin County-Environmental Health Depart PAYMENT <br /> 66, vlainStreet-Stockton CA 95202-Phone: 209• •3420 RECEIVED <br /> APPLICATION -'AIN JOAQUIN; <br /> ENVIRONMENTAL HEALTH EHVIRowt,r,- <br /> PERMIT TO OPERATE HEAirH <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year 2,01 <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#: 39000040 <br /> EH ID#: 39000040 <br /> Please Note any Corrections or Changes in FacilitvIOperator Information directly on this form. <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 9:(415)898-8052 <br /> Legal Owner: PEARCE,JEFF New owner? ❑Yes No <br /> Owner Address: 1680 INDIAN VAL LEY ROAD, NOVATO CA 94947 Owner Phone 9:(415)604-1527 <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: Occupancc Dates: <br /> Buildings Employees <br /> Dormitories from / / to / / Crop <br /> SF Dwellings from / / to / / Crop <br /> Apartments �y ` <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: J <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: rs6 J <br /> MH/RV Spaces Note <br /> TOTALS © Camps occupied by 25 or more Employees for 60 more days in a year <br /> �o Require a PUBLIC WATER SYSTEM <br /> 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 I / <br /> Permanent Camp Annual Permit Fee $35.00+ Number of Employees3 @$12.00 each=$ <br /> Orchard Camp Permit Fee Number of Employees $95.00=$ <br /> ❑ Transfer of Ownership $20.00=$ <br /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> n Late Application Fee $70.00+ Number of Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE S _V d <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 and <br /> maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT,Chapter 1,Part 1,Division 13 of the California Health and Safety Code and <br /> Chapter 1,Subchapter 3,Title 25,C .or is Code of Regulations. L ,,y�, <br /> Applicant Name 3�26AT - 1 Title �Gt� �� ❑Partnership <br /> (Please PRINT or TYPE) d ❑Corporation <br /> Address 16 Ko o ei 041&4, oU uJM CA Z f� Phone <br /> Applicant SignaturegKn Date of Application I�2�/�/2 <br /> Amount Paid Date of Payment Payment Type Check/Receipt# Received By Account ID <br /> �o12-Y6461-- <br /> 0002366 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> EFA0002805 PR0270040 2765 8 8 ALANG WA0461354 <br /> LU <br /> Report#:BBA).rpt Date Application Printed.11/l/2012 <br />