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oaquin County-Environmental Health Depart; I LT 600 E. Main Street-Stockton CA 95202-Phone: 209-46ts-3420 PAYIyENT 2-(5 ` APPLICATION JAN - ENVIRONMENTAL HEALTH 6 20" PERMIT TO OPERATE �'JDA QLj EMPLOYEE HOUSING OR LABOR CAMP H&UT�it)F AR C I ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent(lousing Camps only) ❑Annual Permit for Calendar YearE�r zC ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address Permit ID 4: 0002797 *Additional Employees State ID#: 39000040 Please Note any Corrections or Changes in Facility/Operator Information directly on this form. EH ID#: 39000040 Site Name: PEARCE,JEFF H 39-40 Location: 5125 S KAISER RD,STOCKTON Operator: PEARCE,JEFF H Mailing Address: 1680 INDIAN VALLEY RD, NOVATO CA 94947 Facility Phone#:(415)898-8052 Legal Owner: PEARCE,JEFF H New Owner? ❑Yes 14No Owner Address: 1680 INDIAN VALLEY RD, NOVATO CA 94947 Owner Phone#:(800)303-8400 ::J Community Facilities Provided by Camp: Community Kitchen'? ❑ Yes No Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Employees I Dormitories from �/ /��to �/3(/ Crop SF Dwellings from / / to /_/ Crop Apartments CI Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year © Require a PUBLIC WATER SYSTEM Permit ❑Inactive 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. Fee Schedule I �( 2 Permanent Camp Annual Permit Fe( $35.00+ Number of Employees 2 a $12.00 each=$ 3 ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees a $12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees a $24.00 each=$ Fee must be submitted with Application C TOTAL.FEE DUE$ Remit TOTAL FEE as CALCULATED ABOVE,in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project(camp)shall be operated and 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 Chapter 1,Subc ter , itle 25,California Code of Regulations. Applicant Name F� � �� Title C''1v'uZ lz-- ❑ Partnership (Please PRINT or TYPE ,, , l p / / _ ! ❑ Corporation Address C7 .�1 `' V �( �� 0(r'�� /'/��Phone 2�iJ -Eio/—/fo2� Applicant Signature Date of Application / ,Z 34 1& Amount Paid ate of Payment Payment Type Check/Raca444 Received By Account ID 0002366 Facility ID Program Record ID PIE b Assigned to PWS ID FA0002805 PR0270040 2765 8987-SANGALANG WA0461354 Report#:7066.rot W " �4 0 Application Printed: 11/2/2010