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--n Joaquin County-Environmental Health DeP a ;nt <br /> r~ 11✓/ "1 <br /> 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phone: 209-468-3420 <br /> v <br /> APPLICATION fly U 2006 <br /> 46 <br /> ENVIRONMENTAL HEALTH AQU <br /> yEFNVIpONIN COON <br /> PERMIT TO OPERATE ALTHD AI FNTAC TY <br /> EMPLOYEE HOUSING OR LABOR CAMP ApTM <br /> ❑New Camp []Conditional Permit VkMultlple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year ENT <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 /> E <br /> Please Note any Corrections or Changes in Facility/Operator Information directly on this I 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 /> Housin2 Accommodations to be Utilized this Year: Occupancy Dates: <br /> Buildings Employees /� /� <br /> Dormitories from�/ ( / �7 to (2—/ P/0 h 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& <br /> Owner Owned RR Cars Total Days Occupied by 25 or more Employees: <br /> MH/RV Spaces Note <br /> TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year <br /> Reouire 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 /> 10 Permanent Camp Annual Permit Fe $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 $70.00+ NumbE"i"of E ti—i$loyos t^a, 24;00 t 8cg=S <br /> Fee must be submitted with Application p C <br /> TOTAL FEE DUE$ 1 <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 Chapter 1 cha ter 3 the 25,California Code of Regulations. <br /> Applicant Name �� �� Title d W p Ct Partnership <br /> (Please PRINT or TYPE)r �( l l / ' /` n _❑Corporation <br /> Address � 1 0 % .17&'AA i,W V���G AL� y')Phone <br /> Applicant Signature Date of Application 0 <br /> Amount Paid Da+iurm nt Payment Type Check/Rocai*# Received By Account ID <br /> Y 6 0 0002366 <br /> Facility ID Pro ram Record ID P/E Assigned to PWS ID <br /> FA0002805 PR0270040 2755 3474-VEGA WA0461354 <br /> Report# 7066.rot 0- ��Q���/ Application Printed:11/16/2005 <br />