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S: aquin County-Environmental Health Departs 600 E.,vtain Street-Stockton CA 95202-Phone: 209-4t)- "420 PAY ENT RECDVED APPLICATION Nov 3 0 2009 ENVIRONMENTAL HEALTH PERMIT TO OPERATE SAN JOAQUIN COUNTY EMPLOYEE HOUSING OR LABOR CAMP �,/� ENVIRONMENTAL ❑New Camp ❑Conditional Permit ❑ Multiple Years -(Permanent Housing Camps only) I T(nnual Permit for di il lYWX & ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address D *Additional Employees <:_ `/ Permit ID#: 0002797 Please Note any Corrections or Changes in Facility/Operator Information directly on this I 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 I Owner Address: 1680 INDIAN VALLEY RD NOVATO CA 94947 Owner Phone#:(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: Buildings Employees �/ / I� to �Z /3 / /0 Crop Dormitories 0 0 from SF Dwellings 1 0 from _/_/ to_/_/ Crop Apartments 10 Z! Owner Owned MH/RV 0 0 Total Number of Days to be used this Calendar Year: Owner Owned RR Cars 0 D Total Days Occupied by 25 or.more._Employees: MH/RV Spaces Q Note Camps occupied by 25 or more Employees for 60 or more days in a year TOTALS 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 �G Q Permanent Camp Annual Permit Fe( $35.00+ Number of Employees @$12.00 each=$ c� ❑ Orchard Camp Permit Fee Number of Employees $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late/1 r^,.^t o i Fee $70A0+ Number of Emp!oyees @$24.00 each=$ gyp.. Fee must be submitted with Application TOTAL FEE DUE$ Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EIID 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 Chapt�I,Sub�eh �5,California Code of Regulations. , ��/� ❑Partnership Applicant Name C� Title C(Please PRINT or TYPE) ❑Corporation �- oo �,`Jtl Imo' l 1l/ ,hone � —3Q� 2S 7 ICJ Address c:) 4-'' Applicant Signature I Date of Application / 7115 Amount Paid Date of Payment Payment Type Check/Raeeipt.# Received By Account ID 0\� O 6 q 0002366 ``�3 Facility ID f___�70270040 m Record ID PIE J J Assigned to w PWS ID FA0002805 2765 8987-SANGALANG WA0461354 Report#:7066.rot Application Printed:10/14/2009