BILLING - Laserfiche WebLink

Home Browse Search

s Ioaquin County-Environmental Health Depart t �'�y-iI,', 304 E Weber .venue-Third Floor-Stockton CA 95202-Phont. 209-468-3420 D APPLICATION sgN'/ ��06 ENVIRONMENTAL HEALTH IRoIV/ EMPLOYEE HOUSING ORPERMIT TO LABOR CAMP ATEyEq Ty �IIR 7 t ❑New Camp ❑Conditional Permit Multiple Years(Permanent Housing Camps only Annual Permit for Calendar Year MFNT ❑Amended Permit: *Change of Operator *Change of Owner V I *Change of Operator Address *Change of Owner Address V *Additional Employees Permit ID#: 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 Ornerituress: i6wor Ivn1iAiv VALLEY nC, N 00VA Tv C, 94047 �; ..yaQnm3n4_v+ 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 Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Etnplovecs (- Dormitories from L—/ 1 / O 6 to �Z l 7�t� � Crop tg-1 SF Dwellings from / / to_/_/ Crop Apartments 7 Owner Owned MH/RV Total Number of Days to be used this Calendar Year: 36 1 Owner Owned RR Cars Total Days Occupied by 25 or more Employees: *j- MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Reauire 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 i 1] Permanent Camp Annual Permit Fe $35.00+ Number of Employees @$12.00 each=$ 02, �J / - ❑ 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 S70.00+ Number of Employees (w,S24.00 each=o Fee must be submitted with Application p 0TOTAL FEE DUE$ w 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 Healtle and Safety Code and Chapter 1_Subuhallter 3 the 25,California Code of Regulations. Applicant Name �? �o Title (� ❑ Partnership (Please PRINT or TYPE) ❑Corporation Address �' 0 �-tlJ�l V ��L eC r 'PU 4-1Z' (,`)Phone (j — Y-�UJ2 Applicant Signature Date of Application 6; Amount Paid DatJoikewfinerit Payment Type Check/Rxaiptr# Received By Account ID j ^ Y�0 ^` & 0002366 Facility ID Pro ram Record ID PIE Assigned to PWS ID FA0002805 PR0270040 2755 3474-VEGA WA0461354 T, # 066.rot Application Printed:11/16/2005