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Sac _.quip County-Environmental Health Departme 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: "..>-468-3420 APPLICATION SAt1/,10 2006 ENVIRONMENTAL HEALTH Elvv UI�C PERMIT TO OPERATE NFgCT RO1VMF OUN le EMPLOYEE HOUSING OR LABOR CAMP HUFpgI/NTAI_ ❑ New Camp ❑Conditional Permit Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year MFNT ❑Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit H)#: 0002797 Please Note any Corrections or Changes in Facility/Operator Information directly on this 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 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 Housine Accommodations to be Utilized this Year: Occupancy Dates: Buildines Employees Dormitories from �/ ( / to 2- /0 (--.> Crop SF Dwellings from _/_/ to_/_/ Crop Apartments _ .^ Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 36 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Reouire 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 10 Permanent Camp Annual Permit Fe $35.00+ Number of Employees @$12.00 each=$ o� T / ` ❑ Orchard Camp Permit Fee $95.00=$ ❑ Transfer of Ownership $20.00=$ ❑ Permanent Amendment Fee $20.00+ Number of Additional Employees @$12.00 each=$ ❑ Late Application Fee $70.00+ Number of Employees Via.$24.00.eacn=$ Fee must be submitted with Application O d TOTAL FEE DUE$ �. Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD 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 Chapter 1 cha ter 3 it le 25,California Code of Regulations. �l Applicant Name �� Title Q U-1 41, El Partnership (Please PRINT or TYPE)r (� _ ^❑Corporation Address IQ p NC l V/ tl�-� 4f Phone (j r=�✓L Applicant Signature z Z Date of Application (f Amount Paid DaRoltwmYnt Payment Type Check/R"sipt# Received By Account ID w y 6 -( 6/ 0002366 Facility ID Pro ram Record ID P/E Assigned to PWS ID FA0002805 PR0270040 2755 3474-VEGA WA0461354 Report#:7066.mt Application Printed:11/16/2005