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Sa iquin County-Environmental Health Departm, 600 E. n Street-Stockton CA 95202-Phone: 209-46 .20 PAYMENT RECEIVED APPLICATION NOV 3 0 2009 ENVIRONMENTAL HEALTH PERMIT TO OPERATE SAN JOAQUIN COUNTY EMPLOYEE HOUSING OR LABOR CAMP y� ENVIRON NTAL ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) I(Annual Permit for L� T� ❑Amended Permit: *Change of Operator *Change of Owner T� *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: 0002797 Please Note any Corrections or Changes in Facility/Operator Information directly on this Camp 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 No Owner Address: 1680 INDIAN VALLEY RD,NOVATO CA 94947 Owner Phone 4:(800)303-8400 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: Buildines Employees Dormitories 0 O from / /_/0 to��/3�/ Crop SF Dwellings I 0 from / / to / / Crop Apartments to 2 Owner Owned MH/RV O 0 Total Number of Days to be used this Calendar Year: Owner Owned RR Cars 0 0 Total Days Occupied by 25 or more_Employees: MH/RV Spaces 0 0 Note TOTALS CC-7 ps occupied by 25 or more Employees for 60 or more days in a yea 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 Permanent Camp Annual Permit Fe( $35.00+ Number of Employees / @$12.00 each=$ ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ t"I La:c.1-ppfir ^t:ai Fec $70.00+ Number of Employ ees c^,$14.00 each=e u c F � Fee must be submitted with Application TOTAL FEE DUE$ �292 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,Subchapter ,Title 25,California Code of Regulations. Applicant Name G �C Title Partnership (Please PRINT or TYPE) , / (, ❑Corporation /�^ Address J /YlJ t1 t l� ((� l(fY hone ��U—3Q-3 Applicant Signature Date of Application / 71ti n Amount Paid Date of Payment Payment Type Check/Reeeipt.# Received By Account ID 0002366 Facility ID Program Record ID PIE J Assigned to PWS ID FA0002805 PR0270040 2765 8987-SANGALANG WA0461354 Report#:7066.rpt / ''// J Application Printed:10/14I2009