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Joaquin County-Environmental Health Depa nt P/-\yM,E_NT <br /> 304 E Weber .venue-Third Floor-Stockton CA 95202-Phon_. 209468-3420 RECEIVE-[) <br /> APPLICATION 2007 <br /> ENVIRONMENTAL HEALTH SAN JOAOUIN COUP,. y <br /> PERMIT TO OPERATE ENVIRONME14TAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH D PART - NT <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) KAnnW Permit for Calendar Year o <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 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 V'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 /Dormitories from _L_/ l /_0_T to !' /7 Crop <br /> SF Dwellings from _/_/_to / / Crop <br /> Apartments <br /> Owner Owned MH/RV ` Total Number of Days to be used this Calendar Year: 3�s <br /> Ownei Owned RR Cars Total Days 0ccup1,J by 25 or more Employees: ._ <br /> MH/RV Spaces <br /> Note <br /> TOTALS r Camps occupied by or more Employees for 60 or more days in a year <br /> Require <br /> 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 <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 <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 UV' pter Titie 25,Caiifornia Cudc Qj Reguladons. G <br /> Applicant Name _J 4epr Title Partnership <br /> (Please PRINT or TYPE) El/ _ 1 <br /> Address (f/ �Q ,�-PI v��fi �1/v� � /��f Phone YW "3GC,— y`�J <br /> Applicant Signature Date of Application �j <br /> Amount Paid Date of Payment Payment Type Checkgleceipt# Received By Account ID <br /> �� � � ✓ s �- 0002366 <br /> 3 f, 3 , GL <br /> Facility ID Program Record ID P/E Assigned to PWS ID <br /> FA0002805 PR0270040 2755 3474-VEGA WA0461354 <br /> :Dort#:7066.rot Application Printed:10 /203 06 <br />