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Joaquin County-Environmental Health Depar t PAYMENT 304 E Weber Avenue-Third Floor-Stockton CA 95202-Phon,. 209-468-3420 RECEIVED APPLICATION ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY PERMIT TO OPERATE ENVIRONMENTAL_ EMPLOYEE HOUSING OR LABOR CAMP HEALTH DEPARTMgNT ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year uC0 C?J I]Amended Permit: *Change of Operator *Change of Owner *Change of Operator Address *Change of Owner Address *Additional Employees Permit ID#: 0002797 Please Note any Corrections or Changes in Facility/Operator Information directly on this I 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 10No 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 j Number of Showers (,- Number of Lavatories J Women: Number of Toilets Number of Showers Number of lavatories Housing Accommodations to be Utilized this Year: Occupancy Dates: Buildings Emplovees Dormitories from _/_/ to_/_/ Crop SF Dwellings from _/_/ to_/_/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: J 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 Require 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� r�anent Camp Annual Permit Fe $35.00+ Number of Employees �_ @$12.00 each=$ V ❑ 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 @$24.00 each=$ Fee must be submitted with Application TOTAL FEE DUE$ 3.2 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,Sub apter yTitle 25,California Code of Regulations. Applicant Name I�°' Title Partnership (Please PRINT or TY E) ElCorporation Address . 0 .� /t/�(,' U/ /i _ Ul1 j Phone 1900—303 IW O Applicant Signature ' Date of Application 2 t Amount Paid Date of Payment Payment Type hec Receipt# Received By Account ID •�� / ` fl9 / 0002366 Facility ID D( 0 Program Record ID V P/E Assigned to PWS ID FA0002805 PR0270040 2755 3474-OM WA0461354 Report#:7066.rot �,piy,.�, O(-2 7 7;;2, 0 0 Application Printed:10/29/2004