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PAYMENT <br /> S. oaquin County-Environmental Health Departs RECEIVED <br /> 600 E.Main Street-Stockton CA 95202-Phone: 209-468-3420 <br /> JAN 12 2012 <br /> APPLICATION <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ENVlROMENTAL <br /> PERMIT TO OPERATE HEALTH DEPARTMENT <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑ New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year ��c <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address Permit ID#• 0002797 <br /> *Additional Employees State ID#: 39000040 <br /> Please Note any Corrections or Changes in Facility/Operator Information 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: 1680 INDIAN VALLEY ROAD, NOVATO CA 94947 Facility Phone#:(415)898-8052 <br /> Legal Owner: US BANK NATIONAL ASSN TR ? :;E; ,0XC V New Owner? ❑Yes No <br /> Owner Address: 180 E 5TH ST,ST PAUL MN 55154 f) (IV Owner Phone#:(800)303-8400 <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 / / / /_/ 2- to /2-/.311_t 2- Crop <br /> SF Dwellings from _/_/ to_ / / Crop <br /> Apartments 0 <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 3 � <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> f 07 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 Fe( $35.00+ Number of Employees �_ @$12.00 each=$ 3� <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 Employees @$24.00 each=$ <br /> Fee must be submitted with Application <br /> TOTAL FEE DUE$ 3 <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 Cade and Chapter 1 ha to Title 25,California Code of Regulations. <br /> Applicant Name ,J �� Title 6)&jp r ❑Partnership <br /> (Please PRINT or TYPE) /� ••,�� [I Corporation <br /> Address 16 o ItJ �/Y✓ Z Phone C f,j..�pd/-f fA) <br /> Applicant Signature Date of Application j t' <br /> Amount Paid Date of Payment Payment Type Check/.eceipt# Received By Account ID <br /> -7 0002366 <br /> ..t <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002805 PR0270040 2765 Logged,87-SANGALANG WA0461354 <br /> //�1 Date I f t Z <br /> Report#:7066.rpt e�nV 2 2'L 70z Application Printed:10/25/2011 <br />