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oaquin County-Environmental Health Depart =-;.= t <br /> 600`'1..dain Street-Stockton CA 95202-Phone: 209-4uo-3420 <br /> APPLICATION SAN`CAOUilm Coxls'99>r <br /> ENVIRONMENTAL HEALTH EINV1' vM1EZ:INTA L <br /> PERMIT TO OPERATE <br /> HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year_2^7.4? <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 /> Please Note any Corrections or Changes in Facility/Operator baformatiort directly on this form. 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: 1680INDIAN VALLEY ROAD, NOVATO CA 94947 Facilit. Phone#:(415)898-8052 <br /> Legal Owner: US BANK NATIONAL ASSN TR 7 —j_&0 New Owner? ❑Yes MN No <br /> Owner:>ddress: 180 E 5TH ST, ST PAUL MN 55154 � k Owner Phone 9:(800)303-8400 <br /> Communitv Facilities Provided by Camp: P/ A- Community Kitchen? ❑ Yes ' No <br /> Alen: 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 Emplovees <br /> Donnitories from / / / / / 2- to 12-13// 1 2- Crop dQ'(`($ u(S <br /> SF Dwellings from _/ / to_/ / Crop <br /> Apartments ` <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3E00-- <br /> - <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: , r, <br /> MH/RV Spaces Note rjv, <br /> TOTALS P ® -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 <br /> !� Permanent Camp Annual Permit Fee $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 /> ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ <br /> ❑ Late Application Fee $70.00+ Number of Enmployees @$24.00 each=$ <br /> Fee must be submitted with Application y <br /> TOTAL FEE DUE$ ,9 <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 <br /> and Safety Code and Chapter 1, h apepJj Title 25,California Code of Regulations. <br /> Applicant Name J Title El Partnership <br /> (Please PRINT or TYPE) ❑ Corporation <br /> Address 16 o Phone L/�6.•6r�/—/sue, <br /> Applicant Signature Date of Application j 1 <br /> Amount Paid `Date of Payment t�Payment Type C�h`eck/i e`ceipt# Received By Account ID <br /> 0002366 <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0002805 PR0270040 2765 87-SANGALANG WA0461354 <br /> W 1z "AAW Date 1 1 Z <br /> R po #:7066.m nt) >�2 22 70� Application Printed:10/25/2011 <br />