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r <br /> So ,►aquin County-Environmental Health Depart. <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 <br /> t <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN C ;I,; <br /> CJi <br /> PERMIT TO OPERATE ENVIn� I+,`=1JT <br /> HEALTHAO�d <br /> A <br /> EMPLOYEE HOUSING OR LABOR CAMP NT <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) Annual Permit for Calendar Y <br /> ❑Amended Permit: 'Change of Operator 'Change of Owner <br /> *Change of Operator Address *Change of Owner Address <br /> 'Additional Employees <br /> Permit [D#: 0002797 <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on thi. 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? ❑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 / <br /> Dormitories from 7 to II L��0 7 Crop ��I <br /> SF Dwellings from _/ / to_/ / Crop <br /> Apartments <br /> Owner Owned MH/RV T Total Number of Days to be used this Calendar Year: 3bs� <br /> Owner Owned RR Cars Total Days Occup.'W by 25 of more Employees: <br /> MH/RV Spaces Note <br /> TOTALS /,� Camps occupied by or more Employees for 60 or more days in a year <br /> t Require <br /> a PUBLIC WATER SYSTEM Permit <br /> ❑Inactive <br /> [m ports nt: 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 3 <br /> ❑ Permanent Camp Annual Permit Fee $35.00+ Number of Employees @$12.00 each=$ <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 3 <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 Chapte u ch pter I.Title 25,Cali arnia Code of Regulations. <br /> Applicant Name J � c.� Title ���C� ❑Partnership <br /> (Please PRINTor TYPE) elf, <br /> // Elr <br /> CorpOjOn <br /> Address (f/ eo FJL� I/ `t!�i lJ C/Q / Phone ^3G <br /> Applicant Signature Date of Application / 1 O <br /> Amount Paid Date of Payment Payment Type CheckMecreipi# Received By Account ID <br /> 3 a 3 . \- 3 0 N 0002366 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002805 PR0270040 2755 3474 VEGA WA0461354 <br /> Report#:7066.rot ',� ('S!� `\"- Application Printed:10/23/2006 <br />