Laserfiche WebLink
r"` Joaquin County-Environmental Health Departr- PAYMENT <br /> 600 ain Street-Stockton CA 95202-Phone: 209- i420 RECEIVED <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMENT <br /> ❑New Camp [:]Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Year eL <br /> ol <br /> ❑Amended Permit: *Change of Operator *Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> *Additional Employees <br /> Permit ID#: 0002797 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this Camp 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 RD, NOVATO CA 94947 Facility Phone#:(415)898-8052 <br /> Legal Owner: PEARCE,JEFF H New Owner 7 ❑Yes No <br /> Owner Address: 1680 INDIAN VALLEY RD, NOVATO CA 94947 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 9 <br /> Dormitories from d l p�l�[o l— Crop r <br /> SF Dwellings from _/ / to / / Crop <br /> Apartments <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: <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 /> 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 nn <br /> ❑ Permanent Camp Annual Permit Fe( $35.00+ Number of Employees @$12.00 each=$ 3 0-3 <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 3A3 <br /> TOTAL FEE DUE$ <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,Subchapter 3J'�e 25,California Code of Regulations. <br /> Applicant Name 1 � Title ❑Partnership <br /> (Please PRINT or TYPE) y� ❑Corporation <br /> Address 16 C7 Phone <br /> Applicant Signature Date of Application <br /> Amount Paid Date of Payment Payment Type Check/ eceipt# Received By Account ID <br /> 4���i?J. O D �/3V l0 q ✓ 11�� /J Q 0002366 <br /> Facility ID Program Record ID P/E l Assigned to "lam- PWS ID <br /> FA0002805 PR0270040 5 8987-SANGALANG WA0461354 <br /> Report#:7066.rot /0 Application Printed:10/30/2008 <br />