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I Joaquin County-Environmental Health Depa ant PAYMENT <br /> 304 E Web..- _+venue-Third Floor-Stockton CA 95202-Ph, . 209-468-3420 RECEIVED <br /> APPLICATION <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY <br /> PERMIT TO OPERATE ENVIRONMENTAL <br /> EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMfM7 <br /> ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year 10 0 J <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 this 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 10No <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 j Number of Showers Number of Lavatories l,r <br /> Women: Number of Toilets Number of Showers Number of lavatories <br /> Housine Accommodations to be Utilized this Year: Occu[)ancv Dates: <br /> Buildines Emplovees <br /> Dormitories from _/_/ to_/_/ Crop <br /> SF Dwellings from _/_/ to_/ / Crop <br /> Apartments �_ — <br /> Owner Owned MH/RV Total Number of Days to be used this Calendar Year: J f <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 /> Require 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 Fe $35.00+ Number of Employees &Z @$12.00 each=$ U <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$ 3�3� t> U <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,Sub apter Title 259 California Code of Regulations. <br /> Applicant Name Q c Title Q�u� �L ❑Partnership <br /> (Please PRINT or TY E) ❑Corporation <br /> Address K d -l-/UP�(� U��� _ U(l97C> s Phone �DQ,-303 tI YOU <br /> Applicant Signature /� L c�-e Date of Application j 2 C <br /> Amount Paid Date of Payment Payment Type hec Receipt# Received By Account ID <br /> 0002366 <br /> F3." l.fr+o oil lop / 7 <br /> Facility ID Program Record ID PIE Assigned to PWS ID <br /> FA0002805 PR0270040 2755 3474-OM WA0461354 <br /> Reoort#:7066.rot �111�-t_n/�x� Application Printed:10/29/2004 <br />