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Joaquin County-Environmental Health Depart t <br /> 600 lain Street-Stockton CA 95202-Phone: 209- 3420 <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH <br /> PERMIT TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP <br /> ❑New Camp []Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year <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 rNo <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 /> Housine Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees <br /> Dormitories from to l Z/ .366 t�' Crop <br /> SF Dwellings from _/ / to_/ / Crop <br /> Apartments �t <br /> Owner Owned MH/RV �— Total Number of Days to be used this Calendar Year: 13 6 <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: 3 6 <br /> MH/RV Spaces <br /> 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 f <br /> Permanent Camp Annual Permit Fet $35.00+ Number of Employees 2 J @$12.00 each=$ 3 a <br /> ❑ Orchard Camp Permit Fee $95.00=$ <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$ <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 Cha?!SKJrtiu��apt ,Title 25,California Code of Regulations. S <br /> Applicant Name Cl�/6 ��G� Title 0 �� t �� ❑Partnership <br /> (Please PRINT or PE <br /> '//f /� Corpor oq . <br /> Address /VL (� �,'f L! /C Phone Yod <br /> Applicant Signature Date of Application 124AI,lo <br /> Amount Paid Date of-Payment Payment Type Che eceipt# Received By Account ID <br /> �33s. / Z' 0002366 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002805 PR0270040 2755 2089-SOOD WA0461354 <br /> Report#:7066.rpt �i �} 2 —7L L) Application Printed:10/18/2007 <br />